
Class. 
Book 



COPYRIGHT DEPOSIT 



PLATE I. 




Tubercular Meningitis 
(Page 426.) 



PEDIATRICS 



THE HYGIENIC AND MEDICAL 
TREATMENT 



OF 



CHILDREN 



BY THOMAS MORGAN ROTCH, M.D. 

PROFESSOR OF PEDIATRICS, HARVARD UNIVERSITY 



FOURTH EDITION, REARRANGED 
AND REWRITTEN 



ILLUSTRATED BY NUMEROUS ENGRAVINGS IN THE 
TEXT AND BY COLORED PLATES 




PHILADELPHIA AND LONDON 
J. B. LIPPINCOTT COMPANY 

1903 






COf 

' CnbvuiciM-r r 

- ■. a. 

7<m 



Copyright, 1895, by J. B. Lippincott Company. 



Copyright, 1901, by J. B. Lippincott Company. 



Copyright, 1903, by J. B. Lippincott Company. 



1 < • • 



ELECTROTYPED AND PRINTED BY J. B. LIPPINCOTT COMPANY, PHILADELPHIA, U. S. A. 



TO 



ABRAHAM JACOBI, M.D., LL.D., 

PROFESSOR OF DISEASES OF CHILDREN IN COLUMBIA UNIVERSITY, NEW YORK, 
FROM 1870 TO 1902, 



THE MOST DISTINGUISHED 

STUDENT AND TEACHER OF PEDIATRICS 

IN AMERICA. 



2 J7T££ 



PREFACE TO THE FOURTH EDITION. 

H 

As the third edition of this work is exhausted, it is deemed best, 
in preparing the fourth edition, to make certain changes. Each article 
has been systematically reviewed and carefully revised. Portions of 
the former text have been omitted and replaced by new material which 
recent investigations have brought into prominence. 

Thomas Morgan Rotch. 

197 Commonwealth Avenue, Boston, Massachusetts. 



PREFACE TO THE THIRD EDITION. 



When another edition of this work was called for it was found neces- 
sary to rewrite it in order to bring it into accord with the advances which 
have been made in the subject of Pediatrics during the past six years. 
It is, therefore, offered to the Profession as practically a new book. The 
order in which the different subjects have been treated, and the relative 
space assigned to them, have in many instances been radically changed. 
The endeavor has been made to emphasize the practical character of the 
work by thoroughly systematizing the etiology, the symptomatology, the 
diagnosis, and the treatment of the various diseases. Much attention has 
been devoted to the anatomy and physiology of early life and to the ad- 
vances which have been made in the subjects of infant feeding, of bac- 
teriology, and of the blood. Several new colored plates and a number of 
radiographs have been added to the illustrations. 

In acknowledging the aid which I have received I owe special recogni- 
tion to my associate and friend, Dr. Maynard Ladd, for his help in the 
preparation of the entire book. His interest and enthusiasm have been 
unflagging and invaluable. My thanks are also offered to those who have 
by their advice enabled me to remodel the book, and I would particularly 
acknowledge the information connected with the pathology which has 
been given so freely by Professor William T. Councilman. I am also 
under much obligation to Dr. John H. McCollum, Dr. Robert W. Lovett, 
Dr. John L. Morse, Dr. Algernon Coolidge, Jr., Dr. John Dane, and Dr. John 
T. Bowen. Dr. William P. Northrup supplied for the previous edition 
a number of valuable plates illustrating gastro-enteric diseases, and these 
plates are now retained. Dr. Franklin W. White has been of great ser- 
vice in the preparation of the article on the blood. Dr. Ernest A. Cod- 
man kindly furnished the plates of the radiographs. 

The publishers have shown unfailing courtesy and much liberality. 

Finally, I am greatly indebted to my medical associates throughout the 
country for their encouragement, which has both stimulated me in my 
work and greatly aided me in its completion. 

Thomas Morgan Rotch. 
197 Commonwealth Avenue, Boston, Massachusetts. 



CONTENTS. 



"} 



DIVISION I. 
THE NORMAL INFANT. 

PAGE 

I. — Introduction 2 

II. — The Fcetal Circulation 19 

III.— The Infant at Tekm 21-39 

Yernix Caseosa ; Skin ; Cord ; Spine ; Neck ; Head ; Thorax ; Abdo- 
men ; Bladder ; Pelvis ; Uterus ; Temperature ; Pulse ; Kespiration ; 
Height ; Weight ; Vitality ; Hands ; Peet ; Bone Marrow ; Punctions ; 
Blood ; Lymphatic System ; Urine ; Intestinal Discharges. 

IV. — Normal Development 39-111 

Cord ; Spine ; Neck ; Head ; Thorax ; Abdomen ; Temperature ; Pulse ; 
Kespiration ; Height ; Weight ; Peet ; Bone Marrow ; Skin ; Functions ; 
Lymphatic System ; Thyroid Body ; Urine ; Intestinal Discharges ; In- 
fantile Skeletons ; Normal Infants ; Topographical Anatomy of Early 
Life ; Nursery ; Bathing ; Clothing ; Peet ; Shoes ; Sleep ; When to go 
out ; Nursery-Maids ; Mouth ; School ; Defects of Posture. 

DrvTSiON n. 

FEEDING. 

General Principles 112 

Mammary Gland 114 

First Nutritive Period 116-241 

I. — Maternal Feeding 116 

II. — Direct Substitute Feeding § 160 

Wet-Nurses ; Animals. 

III. — Indirect Substitute Feeding 164 

Cows ; Chemistry of Cow's Milk ; Bacteriology of Cow's Milk ; 
Milk-Laboratories and Percentage Feeding ; Home Modification ; 
Oat-Jelly ; Barley- Water ; Wheat ; Artificial Foods ; Matzoon ; 
Kumyss ; Peptonized Milk ; Malted Foods. 

Second Nutritive Period 241 

Third Nutritive Period 245 

DIVISION m. 

GENERAL PRINCIPLES OF EXAMINATION AND TREATMENT. 

Method of examining a Child 246-256 

Lumbar Puncture ; Kontgen Light ; Treatment ; Prophylaxis. 

DIVISION rv. 

PREMATURE INFANTS. 

Determination of Age 257 

Normal Development 259 

Appearance at Birth 264 

Weight 265 

Incubator (Brooder ) 266 

Food 273 

vii 



Viii CONTENTS. 

DIVISION V. 

DISEASES OF THE NEW-BORN. 

PAGE 

Inheritance. Malformation. Traumatism 282 

Maternal Impressions . . 285 

Diseases of the Head 286-295 

Caput Succedaneum ; Cephalhematoma ; Meningocele ; Encephalocele ; Anen- 
cephalia ; Congenital Hydrocephalus ; Harelip ; Cleft Palate ; Tongue-Tie ; 
Kanula ; Protrusion of Ears ; Ophthalmia Neonatorum. 

Diseases of the Neck 295-296 

Hematoma of the Sterno-cleido-mastoid Muscle ; Branchial Fistulae. 

Diseases of the Trunk 296-31Q 

Mastitis ; Depressed Sternum ; Prominent Sternum ; Spina Bifida ; Rhachis- 
chisis ; Phlebitis and Arteritis Umbilicalis ; Congenital Umbilical Hernia into 
the Cord; Fungus of the Umbilicus; Meckel's Diverticulum; Umbilical 
Hernia ; Inguinal Hernia ; Femoral Hernia ; Hydrocele ; Undescended Testi- 
cle ; Tumors of the Testis ; Malformations about the Rectum ; Occlusion of 
the Vagina ; Hypospadias ; Epispadias ; Congenital Obliteration of the Intes- 
tine ; Congenital Malformations of the (Esophagus and Stomach. 

Diseases of the Extremities 310-312 

Fingers ; Toes ; Club-Hand and Foot ; Congenital Dislocation of the Hip ; 
Congenital Dislocation of the Knee; Birth (Obstetrical) Paralysis. 

General Diseases 312-325 

Asphyxia; Acute Fatty Degeneration of the New-Born (Buhl's Disease); 
Infectious Hsemoglobingemia of the N"ew-Born (Winckel's Disease) ; Hemor- 
rhage in Early Life ; Sclerema Neonatorum ; (Edema Neonatorum ; Icterus 
Neonatorum ; Erythema Neonatorum. 

DIVISION VI. 
DISEASES OF NUTRITION. 

Rhachitis (Rickets) 326-343 

Chondrodystrophia Fcetalis (Foetal Rhachitis). 

Osteomalacia 343 

Scorbutus (Scurvy) 344 

Infantile Atrophy 348 



DIVISION vn. 

DISEASES OF THE SKIN. 

Scabies 355. 

Pediculosis 357 

Impetigo Contagiosa 357 

Furunculosis 35g 

molluscum contagiosum 358 

Seborrhea Capitis of Infants 359 

Tinea Tricophytina 359 

Tinea Favosa 360 

Tinea Versicolor 360 

Alopecia Areata 361 

Pemphigus Neonatorum 361 

Pemphigus • 36I 

Epidemic Pemphigus Infantilis 362 

Dermititis Exfoliativa Neonatorum (Ritter's Disease) 362 

Dermatitis 363 

Sudamin a 365 

Erythema 366 

Erythema Intertrigo 367 



CONTENTS. i x 

PAGE 

Erythema Nodosum 367 

Erythema Urticatum (Urticaria) 367 

Eczema 369 

Psoriasis 372 

Prurigo 373 

Herpes Zoster 374 

Pityriasis 375 

Verruoe (Warts) 375 

Lentigo „ 376 

Melanoderma Lenticularis Progressiva 376 

Lichen 377 

Ichthyosis 377 

Scleroderma 379 

Acute Circumscribed (Edema ( Angio-Neurotic (Edema) 379 

division vni. 

SPECIFIC INFECTIOUS DISEASES. 

Tuberculosis 381-432 

Acute Miliary Tuberculosis ; Chronic General Tuberculosis ; Tuberculosis of 
Lymph-Nodes, of Larynx, of Trachea, of Lungs, of Pleura, of Gastro-Enteric 
Tract, of Peritoneum, of Brain ; Tubercular Meningitis ; Tubercular Dactyl- 
itis ; Tuberculosis of Thyroid Gland, of Thymus Gland, of Pancreas, of Spleen, 
of Liver, of Kidney, of Bladder, of Testicle, of Skin. 

Epidemic Cerebro-Spinal Meningitis 432 

Typhoid Fever 447 

Diphtheria 459-476 

Influenza (La Grippe ) 476 

Malaria 481 

Erysipelas 497 

Amcebic Ileo-Colitis 501 

Cholera Infantum 502 

Cholera Asiatica 505 

Pertussis „ 505 

Acute Infectious Osteomyelitis 511 

Rheumatic Eever (Acute Articular Eheumatism) 514 

Syphilis 520-542 

The Exanthemata 542-613 

Scarlet Fever ; Measles ; Rubella ; Variola ; Vaccinia ; Varicella. 
Parotitis (Mumps) 613 

DIVISION IX. 

DISEASES OF THE MOUTH, NOSE, EAR, NASO-PHARYNX, AND PHARYNX. 

Diseases of the Mouth 615-640 

Nomenclature; Stomatitis Catarrhalis ; Stomatitis Herpetica; Stomatitis 
Ulcerosa; Stomatitis Mycetogenetica ; Stomatitis Hyphomycetica (Thrush); 
Stomatitis Pseudo-Membranosa ; Stomatitis Gangrenosa (Noma; Cancrum 
Oris) Glossitis; Lingua Geographica ; Microglossia; Macroglossia ; Difficult 
Dentition. 

Diseases of the Nose , 640-644 

Rhinitis ; Mucous Polypus ; Epistaxis. 

Diseases of the Ear 644 

Diseases of the Naso-Pharynx 645-649 

Hypertrophy of the Pharyngeal Tonsil (Adenoid Growths). 

Diseases of the Pharynx 649-659 

Tonsillitis ; Peritonsillar Abscess ; Pharyngitis ; Elongation of Uvula ; Retro- 
pharyngeal Abscess. 



x CONTENTS. 

DIVISION X. 
DISEASES OF THE LARYNX, TRACHEA, BRONCHI, LUNGS, AND PLEURA. 

PAGE 

Diseases of the Larynx 660-665 

Laryngospasmus ; New Growths ; Foreign Bodies ; (Edema ; Laryngitis. 

Diseases of the Trachea 665 

Diseases of the Bronchi and Lungs 665-707 

Acute Bronchitis ; Chronic Bronchitis ; Fibrinous Bronchitis ; Bronchial 
Asthma ; Pneumonia ; Pneumococcus Lobar Pneumonia ; Lobar Pneumonia 
due to other Causes ; Acute Broncho-Pneumonia ; Chronic Broncho-Pneu- 
monia ; Hypostatic Pneumonia ; Atelectasis ; Emphysema ; Gangrene and 
Abscess of the Lung. 

Diseases of the Pleura 707-718 

Acute Pleurisy, Dry, Sero-Fibrinous, Purulent (Empyema) ; Chronic Pleu- 
risy ; Hydrothorax ; Pneumothorax. 

DIVISION XI. 
DISEASES OF THE HEART AND PERICARDIUM. 

Diseases of the Heart 719-753 

Congenital Diseases 720-730 

Open Foramen Ovale ; Defect of the Ventricular Septum ; Lesions of the 
Pulmonary Orifice ; Persistence of the Ductus Arteriosus ; Transposition 
of the Large Arteries ; Lesions of the Tricuspid Orifice ; Lesions of the 
Mitral and Aortic Orifices. 

Acquired Diseases 730-748 

Cardiac Hypertrophy ; Cardiac Dilatation ; Myocarditis ; Endocarditis, 
Acute, Chronic ; Mitral Insufficiency ; Mitral Stenosis ; Aortic Insuffi- 
ciency ; Aortic Stenosis ; Tricuspid Insufficiency ; Tricuspid Stenosis ; 
Pulmonary Insufficiency and Stenosis. 

Functional Diseases 748 

Diseases of the Pericardium 754 

Acute Pericarditis ; Chronic Adhesive Pericarditis. 

division xn. 

DISEASES OF THE OESOPHAGUS, STOMACH, AND INTESTINE. 

The (Esophagus 767 

The Stomach 769-783 

Developmental 774 

Functional 774 

Acute Nervous Vomiting 774 

Cyclic or Persistent Vomiting ; Gastralgia ; Acute Gastric Indigestion 

(Acute Dyspepsia) ; Chronic Gastric Indigestion (Chronic Dyspepsia) ; 

Eliminative. 
Organic 783 

Contraction ; Dilatation ; Ulcers ; New Growths ; Acute Gastritis ; 

Chronic Gastritis. 

The Intestine „ 793 

Developmental 795 

Functional 795 

Acute Nervous ; Acute Indigestion ; Chronic Nervous ; Tubular ; 

Chronic Duodenal Indigestion ; Chronic Intestinal Indigestion ; Incon- 
tinence of Fasces ; Constipation ; Eliminative. 
Organic 805 

Acute Fermental ; Chronic Fermental ; Dilatation of Colon ; Volvulus ; 

Intussusception ; Hernia ; Fissures ; Prolapse ; Polypi ; Hemorrhoids ; 

Fistulse ; New Growths ; Proctitis ; Appendicitis ; Ileo-Colitis ; Animal 

Paraeites. 



CONTENTS. xi 

division xm. 

DISEASES OF THE LIVER, PANCREAS, SPLEEN, AND PERITONEUM. 

PAGE 

The Liver 824 

Icterus ; Acute Yellow Atrophy ; Congestion ; Fatty Infiltration ; Suppura- 
tive Hepatitis (Abscess); Hydatids; Biliary Calculi; New Growths; Amy- 
loid; Interstitial Hepatitis (Cirrhosis). 

The Pancreas 840 

The Spleen 840 

The Peritoneum 840 

Acute Peritonitis ; Peritonitis of the New-Born ; Acute Pneuniococcus Peri- 
tonitis ; Chronic Peritonitis. 



DIVISION XIV. 

DISEASES OF THE KIDNEYS, BLADDER, AND GENITAL ORGANS. 

The Kidney 844 

Congenital ; Acquired ; Anuria ; Physiological Albuminuria ; Albuminuria 
of Adolescence: Hematuria and Hemoglobinuria ; Chyluria ; Glycosuria; 
Active Hyperemia ; Passive Hyperemia ; Acute Diffuse Nephritis ; Subacute 
Glomerular Nephritis ; Chronic Interstitial Nephritis (Chronic Bright's Dis- 
ease) ; Amyloid Infiltration ; Acute Pyelitis -and Pyelonephritis ; Chronic 
Pyelitis ; Perinephritis ; Hydronephrosis ; Malignant Growths and Enlarge- 
ment. 

The Bladder and Genitals 867 

Acute Cystitis ; Chronic Cystitis ; Yulvo- Vaginitis ; Orchitis ; Epididymitis ; 
Tumors of the Testicle ; Phimosis ; Enuresis (Incontinence) ; Masturbation. , 



DIVISION XV. 

THE BLOOD. THE LYMPH-NODES. THE DUCTLESS GLANDS. 

The Blood 874-897 

Nomenclature 874 

Normal Conditions 875 

Abnormal Conditions 879 

Leukemia 882 

Pseudo-Leukemic Anemia of Infancy 887 

Primary Anemias 890 

Pernicious Anemia ; 890 

Chlorosis 892 

Secondary Anemias 894 

The Lymph -Nodes 897-898 

Simple Acute Adenitis 897 

Simple Chronic Adenitis 898 

The Ductless Glands 899-909 

Diseases of the Thyroid Gland 899 

Goitre ( Bronchocele ) 899 

Myxcedema ; Cretinism 901 

Exophthalmic Goitre 905 

Acute Thyroiditis 907 

Tumors of the Thyroid Gland 907 

Diseases of the Thymus Gland 907 

Diseases of the Adrenal Glands 908 

Addison's Disease 908 



xii CONTENTS. 

DIVISION XVI. 

DISEASES OF THE NERVOUS SYSTEM. 

PAGE 

Convulsions 910 

Chorea 911 

Epilepsy 916 

Insanity 925 

Idiocy 930 

Microcephalia 932 

Mirror Writing 932 

Hysteria 932 

Hypnotic State 935 

Catalepsy 935 

Simulated Diseases 935 

Insolation 935 

Concussion 937 

Temporary Amnesia 937 

Temporary Aphasia 937 

Arrested Psychical Development 938 

Retarded Speech 938 

Headaches 939 

Vertigo 940 

Pavor Nocturnus (Night-Terrors) 941 

Tremor 942 

Tetany 942 

Dental Reflexes 943 

Nystagmus 944 

Gyrospasm and Spasmus Nutans 944 

Reflex Symptoms of the Ear 944 

Reflex Symptoms of the Larynx 944 

Paroxysmal Gasping 946 

Reflex Symptoms of the Lung 946 

Reflex Cough 947 

Reflex Symptoms of the Heart 948 

Reflex Symptoms of the Stomach 948 

Reflex Symptoms of the Bladder 948 

Reflex Symptoms of the Vagina 948 

Reflex Symptoms of the Rectum 949 

Cerebral Abscess 949 

Cerebral Paralysis (Infantile Cerebral Palsies) 950 

Myelitis 958 

Infantile Spinal Paralysis (Poliomyelitis Anterior Acuta) 958 

Paralysis caused by Caries of the Spine 967 

Obstetrical Paralysis 968 

Neuralgia 970 

Epiphyseal Hyperemia (Growing Pains) 970 

Hydrocephalus 970 

Thrombosis of the Cerebral Sinuses 975 

Athetosis " 976 

Intra-Cranial Tumors 978 

Cerebral Syphilis - 980 

Meningitis 981 

Acute Encephalitis 984 

Bulbar Paralysis 985 

Multiple Neuritis 985 

Insular or Disseminated Sclerosis 987 

Hereditary Ataxia (Friedrich's Disease) 988 

Locomotor Ataxia 989 



CONTENTS. xiii 

, PAGE 

Syringomyelia 989 

Hereditary Spastic Paralysis 989 

Progressive Central Muscular Atrophy „ 989 

Progressive Neural Muscular Atrophy '991 

Progressive Muscular Dystrophies 993 

DIVISION XVII. 

UNCLASSIFIED DISEASES. 

haemophilia 997 

Purpura 998 

Status Lymphaticus (Lymphatism) 1000 

Muscular Rheumatism (Myalgia) 1001 

Arthritis Deformans 1003 

Chronic Rheumatism 1003 

Diabetes Insipidus 1003 

Diabetes Mellitus 1004 

Hypertrophic Pulmonary Osteo-Arthropathy 1008 



LIST OF TABLES. 



TABLE PAGE 

1. Eelation of weight to vitality 37 

2. Length of spine to sacrum 40 

3. Eelation of cricoid to sternum 43 

4. Circumferences of head and thorax from "birth to thirteen years 45 

5. Proportions of face to cranium 45 

6. Height of posterior nares 47 

7. Temporary teeth. First dentition 50 

8. Permanent teeth. Second dentition 51 

9. Post-natal changes of foetal conditions 55 

10. "Weights of the heart during its development 55 

11. Amounts of food in an especial case 67 

12. Three hundred and forty-one infants fed at the milk-laboratory 68 

13. Temperature of infant at term . 70 

14. Townsend's temperature observations „ 71 

15. Pulse-rate for males 71 

16. Townsend's pulse observations 72 

17. Eespirations in infancy and childhood 72 

18. Eespirations in infants awake, asleep, and crying 72 

19. Eate of growth in girls and boys and the relation between growth and disease ... 74 

20. General figures of weight 79 

21. Average height and weights from birth to five years , 81 

22. Average analysis of urine in infancy and childhood 86 

23. Temperature of the bath for different ages 97 

24. Average analysis of five specimens of human colostrum milk 123 

25. General average of twenty-six analyses of human colostrum milk 123 

26. Average analysis of human milk 127 

27. Analyses of fore-milk, middle-milk, and strippings 133 

28. Human breast-milk analyses 134 

29. Intervals and number of day and night feedings 136 

30. Analysis of typical normal, poor, over-rich, and bad milk 140 

31. Analyses of human milk 143 

32. Analyses of human milk 143 

33. Analyses of human milk 144 

34. Analyses of human milk 144 

35. Analyses of human milk 144 

36. Analyses of human milk 145 

37. Analyses of human milk 145 

38. Analyses of human milk 146 

39. Alkalinity of cream mixtures corresponding to that of human milk 175 

40. Cow's milk as compared with human milk 180 

41. General rules for feeding during the first year 188 

42. Practical limits of laboratory modification 199 

43. Practical limits of laboratory modification 199 

44. Table of whey-cream mixtures 201 

45. Showing the management of the food and the increase in weight of a healthy 

infant during the first fifty-two weeks of its life 207 

xv 



xv i LIST OF TABLES. 

TABLE PAGE 

46. Showing the management of the food and the increase in weight of a healthy- 

infant during the first fifty-two weeks of its life 209 

47. Showing lowest possible proteids with creams of different strengths 219 

48. Showing lowest possible proteid mixtures of two, three, four, and four and one- 

half per cent.of fat made from ten per cent, cream 220 

49. Showing lowest possible proteids in mixtures of two, three, four, and four and one- 

half per cent, of fat made from twelve per cent, creams 220 

50. Showing variation of fat percentage in milk of different herds 221 

51. Tor the calculation of home modifications 230 

52. Showing fat percentages obtained by diluting twenty per cent, cream with whole 

milk ."."; 231 

53. Showing dilutions of milk with sugar solutions 232 

54. Showing dilutions of whole milk with sugar solution 232 

55. Showing dilutions of eight per cent, cream with sugar solution 232 

56. Showing dilution of twelve per cent, cream with sugar solution 232 

57. Showing dilution of sixteen per cent, cream with sugar solution 233 

58. Showing combination ot fats and proteids obtained with creams of different 

strengths and whey , 234 

59. Weight for sixty-one days of infant premature at thirty-two weeks 276 

60. Showing details of sixty-four days of life in the incubator of an infant prema- 

ture at thirty weeks facing 281 

61. Differential diagnosis of cerebral meningitis 415 

62. Statistics of tuberculosis of the joints in the Children's Hospital 427 

63. The doses of tincture of digitalis, strychnine, nitroglycerin, and atropine at dif- 

ferent ages 470 

64. The principal combinations of paroxysms caused by the plasmodium malarias .... 486 

65. One thousand cases of scarlet fever, by ages, with the deaths 545 

66. Individuals living in houses invaded by variola 602 

67. Differential diagnosis between varicella and variola 609 

68. Differential diagnosis of the exanthemata 612 

69. Classification of the diseases of the mouth 616 

70. Amount of chlorate of potassium at different ages . 624 

71. Differential diagnosis between a dilated heart and a pericardial exudation 761 

72. Classification of diseases of the gastric enteric tract 773 

73. Normal average number of blood-corpuscles at different ages in cases in which 

there was a loss of weight in the first forty-eight hours 878 

74. Percentages of leucocytes in the normal blood of infants and adults 879 

75. Average percentages of the different elements of the blood in the splenic myelo- 

genous and lymphatic leukaemias 884 

76. Differential diagnosis between cerebral paralysis and poliomyelitis anterior 962 



LIST OF ILLUSTRATIONS. 



COLORED PLATES AND RADIOGRAPHS. 

PLATE PAGE 

I. Tubercular meningitis, convexity of the brain „ Frontispiece. 

II. Icterus neonatorum. Red bone-marrow. Yellow bone-marrow. Erythema 

neonatorum 80 

III. Intertrigo. Seborrhcea capitis. Umbilical cords. Napkins 84 

IV. Radiograph of the chest and abdomen 254 

V. Radiographs of the femora, tibia?, and fibulae in rhachitis, and of the tibiae and 

fibulae in syphilis 836 

VI. Tubercular meningitis, base of the brain 424 

VII. Radiographs of osteomyelitis of the lower end of the femur, and of tuberculo- 
sis of the knee-joint 512 

VIII. Scarlet fever. Measles 564 

IX. Vaccination 604 

X. Varicella. Erysipelas. Syphilis 610 

IX. Mouth and throat in thrush, varicella, stomatitis herpetica, stomatitis ulcerosa, 

follicular tonsillitis, diphtheria 620 

XII. Blood-corpuscles. Mosquitoes, genus anopheles ; genus culex 874 

FIGURES. 

FIG. 

1. Ecetal circulation , 19 

2. Heart, natural size, at two days 20 

3. Spinal curves 23 

4. Sktill of infant at term, natural size 25 

5. Section of foetal lung at five months 32 

6. Section of infant's lung at ten months 32 

7. Lobulated kidney, natural size 34 

8. Stomach, natural size. Infant, three hours old 34 

9. Respiration at birth, illustrative diagram 36 

10. Relative circumference of head, thorax, and abdomen 44 

11. Infant skull, natural size 46 

12. Skulls showing development of ramus at birth, and at three years 49 

13. Eive periods of development in the first dentition „ 50 

14. Eight periods of development in the second dentition 52 

15. Respirations for one-half minute in a healthy infant nine months old 53 

16. Erozen section, child of three years 54 

17. Heart, showing Eustachian valve and foramen ovale 55 

18. Heart, showing ductus arteriosus 55 

19. Stomach, spleen, and pancreas at ten months 57 

20. I., II., III., and IV. Gastric capacity in the first five months of life 60 

21. Stomach of infant two and one-half days old, natural size 64 

22. Stomach of infant five days old, natural size 64 

23. Stomach of infant seven days old, natural size 65 

24. Stomach of infant twelve days old, distended to hold eighty c.c 65 

25. Stomach of infant five months old, distended to hold two hundred and twenty- 

five c.c , 66 

B xvii 



xviii LIST OF ILLUSTRATIONS. 

FIG, PAGE 

26 Stomach of infant seven months old, natural size „ 66 

27. Stomach of infant nineteen months old, natural size . 67 

28. Skeleton of infant at term 87 

29. Skeleton of infant at nineteen months 87 

30 and 31. Normal infant seven months old 89 

32 and 33. Normal development at six years 90 

34 and 35. Normal development at twelve years 92 

36. Infant's bed, Infants' Hospital 94 

37. A, B, C, D, E. Long clothes for infants 100 

38. F, G, H, I, J. Short clothes for infants and children 103 

39. Shape of soles for a child's shoe 105 

40. Posterior spinal curvature from sitting too soon 110 

41 and 42. Lateral curvature of the spine. Child, four and one-half years old Ill 

43. Breast-pump 120 

44. Colostrum milk from cow (photomicrograph) 152 

45. Colostrum milk from women (photomicrograph) 152 

46. Stomach from infant five days' old and glass cylinder of same capacity 187 

47. Centrifugal separator 191 

48. Babcock fat-tester 192 

49. Apparatus for the transportation of milk 193 

50. Ice-box for the transportation of modified milk , 194 

51. Unmodified cow's milk 204 

52. Cow's milk separated and recomposed 204 

53. Human milk 205 

54. Modified cow's milk 205 

55. Apparatus for home modification 224 

56. Sugar-measure 225 

57. Jar containing milk, cream, and siphon 226 

58. Phonendoscope 251 

59. Tongue depressor 251 

60. Foetal stomach, natural size, four and one-half months old 260 

61. Foetal stomach, natural size, seven and one-half months old 260 

62. Foetal stomach, natural size, eight months old 260 

63. Foetal stomach, natural size, eight months old 261 

64. Infant premature at seventh month 264 

65. Infant premature at the twenty-eighth week , 267 

66. Incubator for premature infants 268 

67. Section of incubator 270 

68. Feeder for premature infants 272 

69. Infant premature at thirty weeks. Age, nine months 278 

70. Caput succedaneum. Male, two hours old 286 

71. Double cephalhematoma. Infant, four days old 287 

72. Double external cephalhematoma. Both parietal bones 288 

73. External cephalhematoma. Parietal bone dissected 288 

74. Meningocele. Female, three years old 289 

75. Hydro-encephalocele. Female, two months old 291 

76. Double harelip 292 

77. Congenital depression of sternum. Male, six years old 297 

78. Spina bifida. Male, four and one-half years old 299 

79. Spina bifida of dorsal lumbar region 300 

80. Spina bifida of lumbar region 301 

81. Large umbilical hernia. Infant, five months old 303 

82. I. Normal bone. II. Bone of cretin. III. Bhachitic bone 329 

83. Spindle-shaped rhachitic bone 331 

84. Inner surface of sternum, showing rhachitic rosary 335 

85. Bhachitic kyphosis , 335 

86. Bhachitis, with enlarged spleen. Male, three years old 337 

87. I. and II. Bhachitis. Age, six years 342 



LIST OF ILLUSTRATIONS. xix 

FIG. PAGE 

88. Congenital rhachitis 343 

89. Vertical section of a leg in a case of infantile scorbutus 345 

90. Section of scorbutic bone , 345 

91. Infantile scorbutus. Female, ten months old 348 

92. Infantile atrophy. Female, nine months old 352 

93. Infantile atrophy. Female, ten months old 352 

94. Infantile atrophy. Female, one and one-half years old 353 

95. Infantile atrophy, showing extreme emaciation 354 

96. Tinea tonsurans. Male, eight years old 360 

97. Eczema capitis 371 

98. Method of treating eczema capitis 371 

99. Chronic pulmonary tuberculosis with involvement of the cervical lymph-nodes. 391 

100. Chronic tuberculosis of the lungs. Female, eight years old 398 

101. Tubercular ulcers of the colon , 400 

102. I. Tubercular ulcers of the small intestines 400 

102. II. Large tubercular ulcer of the caecum 401 

103. Tubercular peritonitis. Male, nine years old 404 

104. Tubercular peritonitis. Male, four years old 405 

105. Tubercular meningitis. Male, three years old 418 

106. Recurrent tubercular meningitis. Female, twenty-one months old 422 

107. Tubercular dactylitis 430 

108. Chronic intermittent cerebro-spinal meningitis. Female, eight years old 443 

109. Secondary choroido-iritis, occurring in cerebro-spinal meningitis 444 

110. Chronic cerebro-spinal meningitis, with spastic condition of the hand 445 

111. Typhoid fever. Male, five years old 457 

112. Typhoidal ileo-colitis, showing ulcers of the colon. Female, two years old 458 

113. Enlarged Peyer's patches closely simulating the lesions of ileo-colitis 459 

114. Irrigation of the nose in diphtheria 473 

115. Malaria. Enlarged spleen. Boy, nine years old 491 

116. Malaria. Enlarged spleen. Girl, nine years old 493 

117. Pertussis during paroxysm. Female, four years old 508 

118. Acute articular rheumatism. Adult type of the disease. Male, three and one- 

half years old 518 

119. Rheumatism. Subcutaneous fibrous nodules. Male, thirteen years old 519 

120. Syphilitic maculae, ulcers, and bullae on the soles of the feet. Male, two and one- 

half months old 535 

121. Congenital syphilis. Enlarged spleen. Male, two and one-half months old. . . . 536 

122. Syphilitic teeth of the second dentition 537 

123. Late manifestations of syphilis. Female, three and one-half years old 540 

124. Hereditary syphilis. Male, six years old. Abnormal prominence of frontal bone 541 

125. Interstitial nephritis. Section of kidney from child with scarlet fever 551 

126. Capsular glomerulo-nephritis. Section of kidney from child with scarlet fever. . 552 

127. Typical condition of the face in measles, fifteen days from infection. Female, 

six years old 587 

128. Varicella. Stage of efflorescence, third day 610 

129. Enlargement of submaxillary glands 614 

130. Mycelium of thrush, interspersed with spores and fatty degenerated cells 628 

131. Thrush, showing the formation of spores in the mycelium 629 

132. Stomatitis gangrenosa, left cheek. Female, four years old 632 

133. Stomatitis gangraenosa, secondary to measles and pneumonia. Female, five 

years old 632 

134. Showing the connection between the sensori-motor nerves and the sympathetic. . 635 

135. Showing the anatomical nervous connection between the teeth and the membrana 

tympani 636 

136 and 137. Showing the relations of the teeth to the gums in difficult dentition .... 637 

138. Gum-lancet 638 

139. Hypertrophy of the pharyngeal tonsil (adenoid growths). Female, ten years old 648 

140. Retropharyngeal abscess. Male, seven months old 658 



xx LIST OF ILLUSTRATIONS. 

FIG. PAGE 

141. Retropharyngeal abscess secondary to cervical spondylitis 659 

142. Section of a child's lungs in acute bronchitis 667 

143. Lobar pneumonia. Female, eight years old 688 

144. Lobar pneumonia. Three invasions. Male, six years old 688 

145. Broncho-pneumonia complicating measles. Early stage 692 

146. Bronch-pneumonia secondary to diphtheria 693 

147. Chronic broncho-pneumonia 695 

148. Acute broncho-pneumonia. Female, four and one-half years old 702 

149. Congenital cardiac disease. Unclosed ventricular septum. Female, ten months old 727 

150. Congenital cardiac disease. Stenosis of pulmonary orifice. Incomplete septum 

ventriculorum. Male, four and one-half years old 728 

151. Congenital cardiac disease. Transverse section of heart near apex, showing 

thickened septum ventriculorum 728 

152. Congenital cardiac disease. Open ductus arteriosus. Male, sixteen days old . . . 729 

153. Acute endocarditis. Mitral insufficiency. Lacking compensation. Orthopnoea. 

Female, nine years old 750 

154. Chronic recurrent endocarditis. Mitral insufficiency. Disturbance of compen- 

sation. Dilated heart. Enlarged liver. (Edema of lungs. Ascites. Male, 

ten years old 752 

155. Chronic endocarditis. Mitral insufficiency. General oedema and anasarca 752 

156. Chronic endocarditis. Mitral insufficiency. Returning compensation. En- 

larged liver. Enlarged heart 753 

157. Chronic endocarditis. Mitral insufficiency with returned and complete compen- 

sation 753 

158. Areas of absolute dulness in enlarged heart and in distended pericardium 760 

159. Congenital dilatation of the oesophagus. Female, ten weeks old 768 

160. Colon showing presence of bismuth which had been given by the mouth 774 

161. Dilated stomach. Rhachitic infant, seven months old 784 

162. Dilatation of the stomach. Age, six years 787 

163. Follicular ulceration of the stomach. Female, one year old 788 

164. Dilatation of the colon. Male, twelve years old 810 

165. Hyperplasia of the lymph-follicles 826 

166. Non-ulcerative follicular inflammation. Simple hyperplasia of the lymph-folli- 

cles. Female, three years old 826 

167. Colitis follicularis non-ulcerativa. Male, two years old following 826 

168. Colitis follicularis non-ulcerativa " 826 

169. Microscopic section of hyperplasia of lymph-follicles (solitary glands). " 826 

170. Microscopic section of follicular ulceration of the colon " 826 

171. Ileo-colitis. Ulcerative follicularis. Infant, sixteen months old '•- 826 

172. Acute ulcerative catarrhal colitis. Female, three months old " 826 

173. Inflammation of follicles and surrounding parts of the colon, with 

necrosis. Female, three months old " 826 

174. Pigmented follicular ulcers of the colon. Chronic catarrhal ulcerative 

follicular colitis " 826 

175. Pseudo-membranous colitis. Child, three and a half years old " 826 

176. Microscopic section. Pseudo-membranous colitis. Female, four years old 827 

177. Microscopic section. Superficial necrosis of the mucosa of the colon, with 

swelling of the lymph-follicles 827 

178. Oxyuris vermicularis. Ascaris lumbricoides 830 

179. Tamise, I., without head ; II., with head 833 

180. Amyloid liver. Pulmonary tuberculosis. Male, seven and three-quarter years 

old 838 

181. Hypertrophic cirrhosis. Female, eighteen months old 839 

182. Acute diffuse nephritis, following scarlet fever 855 

183. Probable chronic parenchymatous nephritis with an acute exacerbation. Male, 

eleven years old 860 

184. Probable chronic parenchymatous nephritis with an acute exacerbation. Female, 

nine years old 861 



LIST OF ILLUSTRATIONS, XXt 

FIG, PAGE 

185. Chronic cervical adenitis -. -. 899 

186. Hyperemia of the thyroid gland. Female, thirteen years old 900 

187. Myxcedema. Female, five and one-half years old 903 

188. Myxcedema. Female, nine years old 904 

189. Rheumatic arthritis. Endocarditis, Cardiac enlargement. Chorea. Female, 

eight years old 922 

190. Reflex connection "between the ear and larnyx 946 

191. Cerebral paralysis. Spastic paraplegia. Cross-legged progression. Male, five 

and one-half years old 957 

192. Cerebral paralysis. Diplegia. Female, five years old 957 

193. Poliomyelitis anterior. Left leg. Female, nine years old 965 

194. Poliomyelitis anterior. Abdominal muscles, left side. Female, two and one- 

half years old. . ." 965 

195. Poliomyelitis anterior. Flail-leg, left side. Male, six and one-half years old. . 966 

196. Poliomyelitis anterior. Talipes equinus, right side. Male, eleven and one-half 

years old , 966 

197. Hydrocephalic brain „ 972 

198. Hydrocephalic skull, child three years 972 

199. Normal skull, child three years 972 

200. Congenital internal hydrocephalus. Male, seven months old 974 

201. Congenital internal hydrocephalus. Female, five years old 974 

202. Congenital athetosis. Female, two years old 977 

203. Pseudohypertrophic muscular paralysis, showing enlarged calves 995 

204. Pseudo-hypertrophic muscular paralysis, showing position assumed in rising 

from the floor 995 

205. I. and II. Acute rheumatic torticollis. Fifth day of attack 1002- 



PEDIATRICS 



DIVISION I. 

THE NORMAL INFANT. 



I. INTRODUCTION. 



Pediatrics is a branch of medicine of the greatest practical importance. 
Those who enter into general practice will at once be called upon to treat 
infants and children. The proper appreciation of the sensitive tempera- 
ments and needs of this class of patients will be of great aid in success- 
fully establishing a practice among those whose favorable opinion may 
make or mar professional success. The difficulties to be surmounted in 
correctly diagnosticating and treating young children are far greater than 
those which are encountered in adult life. The reason for this is that for 
adult cases there is some standard by which we can be guided, being our- 
selves adults. What standard, however, is there for the feelings and 
sensitive organization of the child ? We have none within ourselves ; it 
must all come from long and patient observation, with its resulting expe- 
rience. The mere knowledge that certain diseases exist, and the usual 
methods of diagnosticating them, prove to be very inadequate when we 
are brought face to face with a sick and fretful child, or with an infant who 
is unable to describe its symptoms. Much additional knowledge is needed 
to enable us to understand the variety of symptoms wmich may arise in 
the same disease according to the age and individuality of the patient. It 
is now well recognized that there is a necessity for making a special study 
of children beyond what is learned in the general clinical study of adults. 
As our knowledge advances, we learn to appreciate that the various 
methods of treatment must be modified to correspond not so much to the 
special disease as to the special group of symptoms brought about by the 
age of the individual and the phase of its development. In studying, 
then, the different stages of development in children, we are in reality 
acquiring an alphabet, which when once thoroughly mastered will enable 
us to read the otherwise obscure language presented to us for translation 
by the various diseases of early life. The proper method of learning to 

2 17 



18 PEDIATRICS. 

understand sick infants and children is first to notice their peculiarities in 
health and to follow these peculiarities through the different stages of their 
development up to puberty. Thus, a pulse which would indicate an 
abnormal condition in the adult, or a convulsion which would be of 
serious import in the older subject, may often be but physiological or 
of slight consequence in the child. In fact, there are a large number of 
physiological and anatomical truths concerning the young the knowledge 
of which will simplify to a great degree otherwise almost insurmountable 
difficulties in diagnosis. The lack of this preliminary training, this 
alphabet, places the student who is endeavoring to understand diseases 
in children in the position of attempting to read without having first 
learned his letters. It is the province of pediatrics to begin with the 
human being at birth, to study it as it appears in the early hours of life, 
and to follow it in its development during the periods of infancy and 
childhood up to the age of puberty. For purposes of simplicity, we 
speak of infants and children, the anatomical and physiological conditions 
being sufficiently apparent to warrant this distinction between them. The 
period of infancy is usually spoken of as covering about the first two 
years of life. Its most distinctive features are presented in the first 
twelve months, the second year, month by month, rapidly approaching 
the conditions which exist in childhood. The second year, however, is 
influenced to such a degree by the various growing functions and tissues 
that its picture both in health and in disease resembles more closely the 
infant than the child. Childhood is empirically reckoned from the end 
of infancy to puberty, or the beginning of adolescence. A distinction 
must be made between the sexes, the girl becoming a fully developed 
woman some years before the boy becomes a man. The age of puberty 
is usually reckoned as beginning from the twelfth to the fourteenth year. 
Much latitude as to age, however, must be given for the special idiosyn- 
crasy of the individual, and also for the climate, as it has been found that 
children who live in a warm climate arrive at the age of puberty much 
earlier than those who are exposed to the lower ranges of temperature. 
In taking the period of birth as a starting-point for our studies we must 
not overlook the fact that it is simply a stage of development with which 
we are dealing, and not a perfected being. The better, therefore, we 
understand the evolution of the embryo to the infant, the better shall we 
be prepared to appreciate the evolution of the infant to the child and of 
the child to the adult. It is especially important to understand the stage 
of development which exists just before birth, for on this depends the 
knowledge whether we have a physiologically and anatomically normal 
being before us, or one that is abnormal. Disease does not merely mean 
a pathological change in the tissues, but, as is especially well exemplified 
in the infant, may simply mean a retardation or arrest of development. 
Thus, what would be perfectly normal anatomically at the seventh month 
of intra-uterine life may at birth be abnormal, and hence constitute a 



THE FCETAL CIRCULATION. 19 

disease. In like manner what may be normal at birth may if it persists 
into the second and third weeks become an abnormal condition. Disease, 
therefore, is a relative term. We may, however, simplify our classifica- 
tion of diseases by adopting two broad divisions corresponding to the 
changes which take place during intra- and extra-uterine life and desig- 
nated as congenital and acquired. By congenital diseases we mean those 
resulting from changes occurring during intra-uterine life. These may 
arise from an arrest of development or from a continuation of normal 
intra-uterine conditions beyond the usual period of their cessation ; also 
those which are caused by pathological processes such as inflammation. 
By acquired, we mean a pathological condition of existing tissues occur- 
ring after birth, and without regard to the stage of development. 

If we thoroughly understand the anatomical conditions existing just 
before birth, we can intelligently examine the young human being as it 
emerges from the uterus, and can judge in the early days of its existence 
whether we have under our care a normal infant or one that is to need 
special treatment. 

II. THE FOETAL CIRCULATION. 

The chief anatomical change which takes place at birth is the transi- 
tion from the intra-uterine circulatory mechanism to a form adapted to 
extra-uterine life ; in other words, from the oxygenation of the blood 
through the placenta to the same process carried on by the lungs. A 
general knowledge of the fcetal circulation is, then, evidently of consider- 
able importance, especially when it is considered that a large proportion 
of the cases of congenital heart disease which we are called upon to 
diagnosticate is represented by perfectly normal prenatal conditions, such 
as absence of the ventricular septum, an open ductus arteriosus, or a 
patent foramen ovale. 

Fig. 1 represents the course of the (red) oxygenated blood from the 
placenta to the infant, and that of the darker (blue) deoxidized blood 
from the infant back to the placenta. We must consider that in the fcetus 
the lungs are in a collapsed, inert condition, performing no part in the 
fcetal economy, but remaining quiescent until called upon to perform their 
special function at birth. The true lung of the fcetus, therefore, is repre- 
sented by the placenta of the mother. It is here that the blood is oxygen- 
ated, and is carried by means of the umbilical vein directly through the 
umbilicus of the fcetus to the liver, as seen in the diagram. In the liver, 
the umbilical vein divides into three branches : (1) the smallest, carries 
the blood directly to the liver tissue, whence it is returned as in the adult 
to the inferior cava by the hepatic veins : (2) the largest portion meets 
and mixes Avith the blood from the portal system, and is distributed with 
it to the liver ; (3) the remaining portion is carried, by a vessel called the 
ductus venosus, directly to the inferior cava, where it meets the deoxidized 
blood from the lower extremities, mixes with it, and is carried to the riorht 



20 



PEDIATRICS. 



Fig. 2. 



auricle : here, instead of passing as in the adult into the right ventricle, it 
is directed by a membrane, called the Eustachian valve, through an opening 
between the two auricles, called the foramen ovale, into the left auricle. 
It then passes into the left ventricle through the mitral orifice, and thence 
through the aortic orifice into the aorta. The greater part of the blood- 
current is then carried by the carotid and subclavian arteries to the head 
and upper extremities, where, after doing its work in vitalizing the tissues 
and taking up their waste (a small portion also passing, as usual, into the 
descending aorta), it is returned as deoxidized blood through the veins to the 
superior cava into the right auricle, thence through the tricuspid orifice into 
the right ventricle, and up through the pulmonary artery, where a small 
portion is distributed as usual to the lungs, while the remaining portion is 
carried directly over to the descending aorta by a vessel called the ductus 
arteriosus. It here mixes with the small portion of oxygenated aortic 
blood mentioned above, and passes down the aorta, being distributed on 
its way, as in the adult, until it reaches the internal iliac arteries. From 
these arteries it is carried, by branches called the umbilical arteries, through 
the umbilicus back to the cord and placenta. Thus, by simply referring 

to this diagram, we can tell at a glance 
which part of the young infant should be 
most developed, and the reasons for it. 
A noticeable point of clinical interest, in 
tracing the course of the foetal circulation, 
is that the fresh oxygenated blood is mainly 
carried to the liver, head, and upper ex- 
tremities, while the devitalized blood is 
distributed to the thorax and lower ex- 
tremities. We should therefore expect, 
and we shall find it to be true, when we 
examine a normal new-born infant, that 
the head is larger than the thorax, that 
the abdomen is prominent from con- 
taining the large liver, and that the 
legs are insignificant and poorly devel- 
oped. 

When the placental circulation is cut 
off, an increased amount of blood is carried 
by the pulmonary artery to the lungs, and 
by degrees the foetal circulation is replaced 
by that of extra-uterine life. 
The ductus venosus and ductus arteriosus become fibrous cords. 
The Eustachian valve disappears. 
The foramen ovale closes. 

The umbilical vein and umbilical arteries become obliterated, with the 
exception of the lower parts of the latter. 




* 



Heart, natui 



at two days. A 



marks the aorta ; PA marks the pulmo- 
nary artery ; DA marks the ductus arteri- 
osus. 



THE INFANT AT TERM. 21 

During the first two weeks of infancy we may have conditions exist- 
ing physiologically which after that time would become pathological, and 
hence, to be well grounded in the diagnosis of disease in the infant, we 
must appreciate the importance of these facts. 

Fig. 2 represents a heart taken from an infant two days old. It is of 
natural size, and shows the ductus arteriosus connecting the aortic and 
pulmonary arteries. 

III. THE INFANT AT TERM. 

By the infant at term we mean one that has been born at the termina- 
tion of what is considered the usual period of pregnancy, two hundred 
and eighty days. 

SKIN. — A normally developed foetus when it first emerges from the 
uterus has a reddened skin and is covered thickly in many parts by a 
substance made up of the contents of the amniotic sac, in which the 
foetus has been floating, and of the excretion of the sebaceous glands. 
This substance is called the re mix caseosa. In certain rare cases also 
this sebaceous matter is so universal and so impenetrable as to constitute 
a disease of serious import, and at times even to cause death. Infants 
also may be born with the skin almost entirely free from the vernix caseosa. 
After the infant has been bathed, and the vernix caseosa has been removed, 
it should present the color of a healthy skin reacting normally to its external 
surroundings. The skin should usually be some shade of delicate pink. 

General Description. — The body and limbs should be well rounded, 
the cry vigorous, the extremities warm, and the grasp of the hands strong 
and active. The hair at birth is often thick, dark, and quite long, perhaps 
2 to 5 cm. (1 to 2 inches), but we also frequently find the hair to be short, 
fine, some shade of light brown, small in amount, and the temples bald, the 
hair coming down to a round point on the forehead. The eyes are almost 
always half open when awake, expressionless, and of a dull grayish blue. 
The head is large in comparison with the thorax, the arms more rounded 
and large in proportion to the legs, and the abdomen is prominent. 

The cord dries up and falls off at about the sixth or seventh day. 
It is important to know how it should look normally up to the day when 
it separates from the umbilicus in order to distinguish it from abnormal 
conditions. There is a slightly reddened areola where it joins and is to 
part from the abdominal wall. (Plate III.) 

Palpation, percussion, and auscultation show that the heart has about 
the same proportionate position in reference to the lungs as is found in 
the adult, but that the liver occupies much more space, coming fully 1 to 
2 cm. (J to 1 inch) below the edge of the ribs in the right hypochondriac 
and the epigastric regions, and encroaching on the lung-space in the right 
back to the extent of fully one rib and interspace. The testicles have de- 
scended, and the bladder, when full of urine, presents an area of dulness 
of about 2 cm. (1 inch) just above the pubis in the median line. It is an 



22 PEDIATRICS. 

important fact that the bladder is an abdominal rather than a pelvic organ 
in the infant and young child. The dull area of the spleen corresponds 
in its position to that found in the adult, but is scarcely perceptible. 

The following anatomical and physiological truths relating to the infant 
at term are based on what is usually found to exist in the average infant. 
I am especially indebted to Professor Thomas Dwight for the assistance 
which he has given to me from his own original investigations, and from 
his verification of the anatomical part of the work. It has not been at- 
tempted to give the complete anatomy and physiology of the various 
periods of early life, but merely to pick out the practical points in these 
periods which will aid in clinical diagnosis and treatment. The great 
importance of thoroughly understanding the normal anatomy and physi- 
ology of human beings before attempting to deal with the morbid condi- 
tions which arise in them is now so well recognized that no preliminary 
remarks are needed to show how vital to all advance in clinical medicine 
is the proper reading of anatomical and physiological truths. There are 
several points in the anatomy and physiology of the new-born infant which 
would be better understood if the fact were borne in mind that in many 
respects the body at this age is more adapted to its intra-uterine life and 
to its means of exit into the external world than to the conditions which 
surround it in extra-uterine life. 

It is not uncommon at birth for the face to be swollen and the features 
out of shape ; this comes from pressure, and will soon pass away. 

At birth the trunk is egg-shaped, the larger end being below. The 
pelvis as a region hardly exists, and the thorax is very small when com- 
pared with the large abdomen. The latter is very large, owing to the 
disproportionate development of the liver, presumably a great organ of 
nutrition during fetal life. A striking peculiarity is the almost complete 
absence of shoulders, which with the arms are relatively insignificant out- 
growths from the sharp end of the egg. It is evident that the small size 
of the thorax, its Avant of solidity, and the slight development of the 
pectoral and shoulder muscles indicate that its action in respiration must 
be very different from that in adult life. 

The greatest breadth of the trunk is in the region of the lower ribs. 

During intra-uterine life, and especially at the time of delivery, great 
flexibility and compressibility are requisite. Respiration has not yet oc- 
curred, and the assimilation of nutriment for the growth of the body and 
for preparing the rudiments of future organs has been the function most 
actively employed. When, therefore, we study the new-born infant, we 
must remember that we see it at an essentially transitional stage. Adap- 
tations, the marked utility of Avhich is past, still persist, and new func- 
tions are carried on with very imperfect apparatus. 

SPINE. — At birth the spine consists of little bone and much cartilage 
and fibrous- tissue. It can be twisted and bent at will in any direction. 
It appears relatively broader in proportion to its length than does the 



THE INFANT AT TERM. 



23 



adult spine. The height of the vertebrae is relatively less, and appears 
even less than it is, from the fact that the broad, narrow, bony nucleus 
of the vertebral body, which catches the eye, does' not represent the whole 
thickness of the body, as it is embedded in cartilage. 

At this early stage of development the whole column is cartilaginous, 
with the exception of the nuclei of the bodies of the vertebrae and those 
of the laminae on either side, forming a small portion of the body and 



Infant at birth. 



Fig. 3. 
SPINAL CURVES. 
Infant sitting. 



Infant standing. 



Front — *- 



D 




(2) (3) 

C represents cervical curve ; D represents dorsal curve ; L represents lumbar curve ; S represents 

sacral curve. 



the beginning of the arch. The time of the consolidation of the bodies 
is not accurately known. 

In the young embryo, the proportion of the neck in the movable part of 
the spine is greater than that of the loins, a condition which is reversed 
in the adult, where the neck is less, being a little over one-fifth, and the 
loins a little less than one-third. In fact, the proportions of the spine 
change considerably from an early period of intra-uterine life to that of 
the perfected adult condition. At birth, however, the change has pro- 



24 PEDIATRICS. 

gressed sufficiently to make these two parts very nearly equal. The 
union of the laminae to form the spine begins in the upper part of the 
spine sooner than in the lumbar region. Throughout the greater part 
they are nearly united, and in some places are quite joined, at birth. 

Fig. 3 represents (1) the natural curve at birth, (2) the curve which 
comes especially in the cervical region when the infant has learned to sit 
up and the superincumbent head has to be supported, and (3) the addi- 
tional dorsal and increased lumbar curves which appear when the child 
stands, and walks, and which correspond to those of the adult condition. 

At birth, when the child is lying in what may be called its normal 
position, — that is to say, on its side, with the head flexed and the thighs 
drawn up, — the whole spinal column presents one long concavity from 
the atlas to the coccyx, the front of which is subdivided into two curves 
by the slight projection of the promontory of the sacrum. Above this 
there is a tolerably regular concavity. The head can be thrown back so 
as to make a slight convexity in the neck, and by bringing the knees 
against the table (the infant being on its back) the lumbar region will 
spring forward ; but the former of these positions is rather unnatural, and 
the latter impossible without assistance. We can then consider the part 
of the spine above the sacrum as essentially a fibrous and cartilaginous 
rod, with a number of separate disks of bone embedded in it at different 
places. The extent of the movements possible at birth, both in the dis- 
sected spine and in the whole body, is remarkable. 

At all ages, from birth upward, the spine of the fourth lumbar verte- 
bra is (as in the adult) on a level with the highest point of the crest of 
the ilium (Dwight). Under certain circumstances this might advanta- 
geously be used as a starting-point from which to count. At birth the 
spinal cord descends only the space of about one vertebra lower than in 
the adult. The third lumbar spine, which should mark its termination, 
cannot be easily recognized under three years, but the correspondence of 
the top of the ilium with the fourth vertebral spine allows its position to 
be estimated. It is desirable to know how far the cavity of the spinal 
dura mater descends inside the sacrum. Recent investigations by Wagner 
show that in children under a year old it ends usually near the top of the 
third sacral vertebra, which makes it a little lower than its usual termina- 
tion in the adult. The point on the surface corresponding to this could 
be approximately estimated without any definite landmarks. 

NECK. — It is customary to say that young babies have no necks ; and 
yet when speaking of the spine it was stated that the cervical region of 
the vertebral column of the infant and young child is relatively longer 
than in the adult. From this point of view the shortness of the infant's 
neck must be seeming rather than real, but from a clinical stand-point it 
is real enough. The causes of the short neck are, first, the large head, 
which naturally falls forward, covering the upper portion, and next, the 
high position of the sternum encroaching on it from below. The large 



THE INFANT AT TERM. 



.25 



proportion of subcutaneous fat tends to make the neck appear still 
shorter. 

The larynx is at first placed much higher than later (Symington). 
In the adult the lower border of the cricoid is about on a level with the 
top of the seventh vertebra. In the infant it usually seems to be near the 
lower border of the fourth vertebra. 

HEAD. — Young infants frequently have at birth a startling shape to 
their heads produced by pressure. One side of the skull may be flattened, 
while the other bulges, or the natural diameters of the head may be 




Skull of infant at term, natural size. Posterior view, showing parietal and occipital bones and posterior 
fontanelle. Warren Museum, Harvard University. 



altered, presenting a long, narrow head instead of a round, well-formed 
cranium. These shapes at times give an idiotic expression to the infant 
which causes much distress to the parents. In almost every case these 
abnormal appearances pass away in a few months, as the skull and brain 
grow, and do not, as a rule, indicate disease unless very extreme, so that 
it is well to state this fact to parents at once and thus to relieve their 
minds. As a rule, if the measurements of the head are taken over the 
middle of the forehead and around to the occipital protuberance, it will be 
found that at birth the circumference is about 33 cm. (13 inches). 

Fontanelles. — The opening between the frontal bones and the anterior 
borders of the parietal bones is called the anterior fontanelle, and, though 



26 PEDIATRICS. 

somewhat depressed below the level of the bones at first, should soon be 
about on a level with them. Its size is variable, but is usually about 2 to 
3 cm. (J to 1 1 inches) long, and about 2 cm. (J inch) wide. In the early 
days and even weeks of infancy the frontal suture is usually open in its 
upper part, as shown in Fig. 28, facing page 86. 

The opening between the occipital bone and the posterior edges of the 
parietal bones is much smaller, is of less significance than the anterior 
opening, is often temporarily obliterated by the overlapping of the bones, 
and is called the posterior fontanette. 

Face and Cranium. — In infants the proportion of the face to the cra- 
nium is strikingly different from what is found in adults, where it is as one 
to two, while according to Froriep the face in the infant is to the skull as 
one to eight. 

If the front view of the face and cranium of the infant and of the 
adult is contrasted by counting as face all below a line at the tops of the 
orbital arches, and as skull all that is seen above that line, considering it 
projected on a vertical plane as in a photograph, it will be found that in 
the infant the skull forms about one-half, and in the adult much less. 

The height of the orbit bears pretty nearly the same proportion to the 
skull at all ages, except that it equals barely a third of the adult face, 
while it makes nearly a half of it at birth. While the top of the nasal 
opening retains pretty nearly the same relation to the orbit at all ages, its 
lower border is but very little below the lowest point of the orbit at birth, 
while it is much below it in the adult. In the latter,, a line connecting 
the lowest points of the malar bones crosses the nasal cavity, or at least 
touches its lower border, while in the infant it runs almost half-way be- 
tween the lower border and the edge of the alveolar process. The 
breadth of the skull in its greatest diameter in the infant equals, or even 
exceeds, the total height of the skull and the face, while in the adult it is 
but about three-quarters of it. Still more striking is the difference be- 
tween the length and the breadth of the face at different stages. The 
breadth, measured between the most distant points of the zygomata, is to 
the height of the face in the adult about as nine to eight, while at birth it 
is perhaps as much as ten to four. 

The side view is equally or even more characteristic. The auditory 
meatus is situated about midway between the front and the back in the 
infant, but in the adult it is decidedly behind the middle. The face appears 
to be but an insignificant part of the whole structure. 

Jaws. — The lower jaw is almost on the same plane as the mastoid 
process of the temporal bone, and the upper border of the zygoma is 
about on a level with the floor of the nasal cavity, while in the adult it is 
at or near the level of the floor of the orbit. It is evident that a very 
important factor in the adult face is the development of the jaws and of 
the teeth, and that it is due to their rudimentary condition that the face is 
so small in infancy. The difference in the comparative development of the 



THE INFANT AT TERM. 27 

lower jaw at birth and at three years is well exemplified by the skulls 
shown in Fig. 12, page 49. 

Gums. — The gums do not meet in the new-born (McClellan). They 
are composed of a dense fibrous tissue covered by vascular mucous mem- 
brane of very slight sensibility, and are protective to the growing teeth. 

Naso-pharynx. — A median section of an infant" s head shows very 
strikingly the want of height of the naso-pharynx and the great obliquity 
(approaching the horizontal) of the posterior edge of the vomer. The 
naso-pharynx is relatively very long from before backward. Strange as 
it may seem, the distance from the back of the hard palate to the soft 
parts of the back of the pharynx (excluding the tonsil) is about as great 
at birth as in the adult. A knowledge of the change in size and shape of 
the nasal cavities and naso-pharyTix in the course of growth is very impor- 
tant. The nasal cavity consists of an upper olfactory region, occupying 
the ethmoidal portion of the cavity, and a lower respiratory region occu- 
pying the maxillary part. In the infant the nasal cavity is relatively long 
and shallow, and the respiratory portion is very narrow. 

The height of the posterior nares at birth is 6 to 7 mm., and the 
breadth between the pterygoid processes at the hard palate is 9 mm. 
(D wight.) 

In the infant the naso-pharynx is simply a narrow passage running 
obliquely backward and downward from the constricted opening of the 
posterior nares. The soft palate of the child is placed more horizontally 
than in the adult. The posterior nares (not the inferior meatus alone, 
but the whole opening on either side) is just large enough to admit the 
end of a medium-sized male catheter ; this leads into the passage just 
mentioned, and therefore a congestion of the nasal mucous membrane in 
infancy, with the addition of the mucous secretion, may effectually close 
the opening from the nose to the pharynx. 

It is. perhaps, not sufficiently recognized clinically how important a 
function is performed by the nasal passages in early infancy, — far more 
important, indeed, than at any other age. In fact, the age of the infant 
is in inverse ratio to the dangers which may arise from obstruction of the 
nares. 

These dangers, consequent on obstruction, congestion, and the result- 
ing mechanical disturbance of neighboring parts, thus leading to actual 
disease of those parts, become in the new-born infant of most serious and 
even vital import. I have seen an infant die of simple acute nasal catarrh 
in the first two or three days of life. In this case the infant was, indeed, 
puny and ill cared for. 

There is no doubt that, with due appreciation of the value of the 
nasal function and the danger of allowing it to be interfered with, we can, 
as a rule, even in extremely weak infants, prevent a fatal result. 

Lymph- Vessels of the Pharynx. — An anatomical condition of great 
importance is that in comparison with the faucial tonsils, which are rela- 



28 PEDIATRICS. 

tively poor in absorbents, an exceedingly rich plexus of absorbents exists 
in the posterior wall of the naso-pharynx. 

Eustachian Tubes. — In the foetus the nasal opening is below the level 
of the hard palate, which it reaches at birth. While in the adult the car- 
tilaginous portion slants downward, nevertheless the opening of the tube 
is opposite a higher part of the nose than in the child. At birth the tube 
is horizontal or nearly so. It must be borne in mind that even if the 
opening of the tube be below the level of the hard palate, the soft palate 
none the less runs beneath it, shutting it off from the cavity of the mouth 
and the passage from it to the fauces. 

In the infant and in the young child there is but a slight development 
of the end of the cartilage which makes in the adult so prominent a fold 
at the back of the pharyngeal opening of the tube, and by its prominence 
does much to determine the depth of the fossa of Rosenmiiller, the recess 
behind it at the lateral posterior angles of the pharynx. At birth this 
prominence hardly exists. The opening of the tube is at first very small. 
That the catheterization of the tube at this age presents great difficulties of 
its own, apart from the intractability of the patient, is sufficiently obvious. 

The tube in infancy, while of course shorter than in the adult, is stated 
to be not only relatively, but absolutely, wider at its narrowest point, 
which may explain the case with which catarrhal processes travel at that 
age to the middle ear. 

Paucial Tonsils — Pharyngeal Tonsil — Lymphoid Tissue. — The 
faucial tonsils, the pharyngeal tonsil, the lymphoid masses under the 
mucous membrane of the posterior third of the tongue, the lymphoid 
tissue about the orifices of the Eustachian tubes, to say nothing of irregu- 
lar aggregations of the same tissue in the neighborhood, form a lymphoid 
ring around the pharynx which is most important. It is to be noticed 
that the passage from the nose, as well as that from the mouth, is guarded 
by this apparatus. That its function is in part protective seems very 
probable, in spite of the fact that when hypertrophied it gives rise to 
serious trouble. Before birth this system is but slightly developed. In- 
deed, the follicles at the back of the tongue are not always to be found at 
that time. 

A pocket in the pharyngeal tonsil is the famous bursa pharyngea. It 
is clinically important merely as a recess in which inflammation may 
linger and secretions be retained. 

The supposition that this system is protective receives support from 
Killian's observation that the pharyngeal tonsil is much developed in 
mammals that live in the dust of houses. It is not impossible that this 
lymphatic ring forms a bulwark against septic invasion. 

Gooclale's investigations show that bacteria are found in the tonsillar 
crypts and that such organisms may be absorbed in the gland, but as soon 
as absorbed they meet with such conditions as would be likely to termi- 
nate their life. The small size of the naso-pharynx in the infant and the. 



THE INFANT AT TERM. 29 

young child explains its obliteration by the enlargement of the pharyngeal 
tonsil. 

Mouth. — The mouth, as a whole, is pre-eminently an organ intended 
for the reception of a liquid food, its mechanism being that of suction. 
It is a natural and necessary passage-way to the organs of digestion, but 
is not at first intended to aid the digestion by a salivary secretion. 

Tongue. — The tongue at birth is slightly coated and comparatively 
dry. It is greatly wanting in vertical thickness, and on section is shown to 
be long and narrow. The soft palate, therefore, rests on the tongue, and, 
the mouth being closed, runs in the main backward, descending very much 
less than in the adult. The uvula is rudimentary (Merkel). Owing to 
the depth of the pharynx (from before backward), the soft palate is unable 
to shut off the passage to the naso-pharynx as completely in early infancy 
as subsequently. 

Teeth. — At birth there are twenty embryo teeth, ten in each jaw, en- 
veloped in their respective tooth-sacs, protected above by the submucous 
tissue and mucous membrane, on either side by alveolar bone-substance, 
and below by the groove in the maxillary bone from which the alveoli 
have developed. 

Hard Palate. — At birth and in the early months of life the line of 
the hard palate, continued backward, strikes near the top of the basi- 
occipital, that is, near its junction with the sphenoid, or perhaps even 
strikes the latter. Accordingly, at this age, if the finger be introduced 
directly backward through the mouth, pushing the soft palate upward, it 
will strike the occipital bone, and being carried a little downward, will 
pass over the arch of the atlas, the base of the odontoid, and the body 
proper of the axis. Going still lower, the top of the third cervical verte- 
bra might be felt, but the larynx would hardly permit the finger to go 
lower, and the parts are so small that it is questionable if much could be 
recognized below the axis. 

Brain. — The brain of the new-born infant is proportionately very much 
larger than in the adult, bearing a relation of about 15 to 1. (Vierordt.) 

Eye. — The eye is anatomically perfectly developed in the new-born. 
(McClellan.) 

Ear. — The development of the ear is in its several parts very unequal 
(McClellan). The structures of the internal ear, the tympanic cavity, and 
the auditory ossicles are fully formed at birth, while the external auditory 
meatus, the Eustachian tube, and the mastoid portion of the temporal 
bone undergo many modifications before their full development at puberty. 
At birth the meatus passes inward and inclines downward, and the mein- 
brana tympani is almost horizontal, conditions to be remembered as 
necessitating a little different management of the ear speculum from what 
is taught in the examination of the adult ear. 

The mastoid antrum exists at birth, but the cells do not develop until 
later. 



30 PEDIATRICS. 

Petro-Squamosal Suture. — An important anatomical condition exist- 
ing at birth is, that the petro-squamosal suture is open, allowing a close con- 
nection between the blood-vessels of the brain and the middle ear, with 
its resulting clinical significance. 

THORAX. — The thorax of the infant forms the upper and smaller 
end of the egg-shapecl body which has been already described, while the 
small shoulders make the chest very different from that of the adult. 
Besides this, the whole shape of the thorax is very peculiar. The pro- 
portion of the dorsal region of the spinal column is pretty nearly the 
same throughout life, but the thorax itself varies greatly. At birth the 
thorax is very insignificant. In front the breast-bone is relatively much 
smaller than that of the adult male, but not very different from some 
very small breast-bones which are occasionally met with in women. The 
lower part is, however, but slightly developed. The borders of the ribs 
diverge relatively rapidly. This is perhaps due to the great breadth of 
the abdomen. 

Top of the Sternum. — The sides of the thorax are not relatively so 
long as in the adult, which is probably partly due to the lesser develop- 
ment of the lower ribs and partly to the very important characteristic of 
the infant's thorax, — namely, that the top of the sternum is placed higher 
than in the adult. The top of the sternum in the latter is about on a 
level with the disk between the second and third dorsal vertebrae. The 
top of the sternum, according to Symington, is opposite about the middle 
of the first dorsal vertebra in the new-born infant, and a frozen section 
by Riidinger shows it to be rather below the middle of the first. 

Diameters. — Another most important peculiarity of the infantile and 
child's thorax is its want of breadth. In the adult throughout the thorax, 
from about the level of the second costal cartilage, or even a little higher, 
to the top of the diaphragm, the antero-posterior diameter of the interior 
of the thorax is to the transverse as one to two and a half or one to three, 
there being, of course, a certain amount of variation. At birth, on the 
other hand, it is as two to three. 

It is well known that in the infant the ribs are more nearly horizontal 
than in adult life. A striking feature of the young infant's chest is that the 
ribs form the sides of the chest, and the sternum and cartilages the front. 

Ossification. — At birth the sternum is practically a strip of cartilage 
in which a varying number of bone-centres have been deposited. There 
is one for the manubrium and usually one or two for the second and 
third pieces, those for the latter being very, frequently double. These, 
however, are mere thickenings of the cartilaginous strip, which is flexible 
and pliable in all directions. (Figs. 28 and 29, facing page 86, show these 
divisions of the sternum.) 

Respiration. — An important feature in the mechanism of thoracic res- 
piration is the rigidity of the thorax. In the infant at birth this rigidity 
is almost wholly absent, as it is found only in the ribs. 



THE INFANT AT TERM. 31 

The sternum is at this age practically a perfectly flexible strip of carti- 
lage, for the small points of ossification in it only modify the softness of 
certain separate parts. The dorsal region of the spine is not fixed as a 
concavity, but can be bent freely backward. The motions of the ribs are 
practically the same as in the adult, but the effect of these motions is 
different. In the first place, as has been shown, the ribs are more nearly 
horizontal, and the thorax, even after death, is in what is called the in- 
spiratory condition. The nearly horizontal first rib can hardly rise any 
higher unless the whole spine is bent backward. The ribs, being straighter 
than in the adult, do not when raised increase the breadth of the chest to 
the same degree. The nature of the infantile respiratory movements is 
far from easy to analyze. Sometimes it seems abdominal and sometimes 
thoracic. The fact is, that at first it is of a very indefinite type. The 
thorax seems to expand as it can. It is common to see its lower 
part drawn inward by the contraction of the diaphragm. At birth no 
especial part of the respiratory apparatus has attained a sufficient develop- 
ment to insure its continuous equable action, and, as would be expected, 
irregular respiratory movements and no decided type of respiration are 
found. 

A sufficient number of observations, however,. have not yet been made 
to warrant our stating any especial age at which the type of respiration in 
the two sexes separates and the female infant assumes the thoracic type of 
respiration. But if the breathing of the infant is essentially irregular in 
type, it is admirably adapted to the wants of its age. The elastic thorax 
can give way under pressure and expand in almost any direction,, The 
flexible sternum submits to liberties which no adult breast-bone would 
endure. One-half of the chest may be compressed and yet the other go 
on acting independently. 

The facts that the top of the sternum is higher, reckoning from the 
spine, that the ribs are more nearly horizontal, and that probably the 
lower part of the sternum is relatively less developed than in the adult, — 
necessarily imply certain peculiarities in the relations of the internal parts. 

Diaphragm. — The diaphragm rises highest on the right over the summit 
of the liver, is a little lower on the left, and lower still at its tendinous 
centre in the median line. It is generally stated that the diaphragm is 
higher in the child than in the adult. D wight's observations, partly origi- 
nal, partly on the frozen sections of other writers, give the following re- 
sults. In the infant the diaphragm appears to be opposite the disk between 
the eighth and ninth dorsal vertebrae. In the infant it appears as if there 
were a lower insertion of the diaphragm to the sternum and the seventh 
costal cartilages than in the adult.' Usually the line runs from one costal 
arch to the other, somewhat above the apex of the ensiform cartilage, 
leaving, therefore, a space on either side of the latter, where the interior 
of the thorax is against the abdominal walls. Owing, perhaps, to the 
greater flexibility of the body and to the less firm attachment of the in- 



32 PEDIATRICS. 

ternal parts one to another, it certainly seems that at least after death the 
thoracic cavity is more accessible at the sides of the ensiform than it is in 
the adult. 

We may conclude that, while there is some variation, on the whole, 
the central point of the diaphragm is in the infant higher in relation to the 
spine than later in life, and that it gradually becomes lower. How high 
the diaphragm rises laterally is hard to say, for it is a point very difficult 
to observe. According to Kolliker, in the foetus at term, on the right it 
reaches the level of the anterior end of the fourth cartilage, and on the left 
that of the fourth intercostal space. Henke adds to this that certainly 
after respiration has begun it will never be so high again. 

Thymus Gland. — The thymus gland exists at birth, and lies above and 
to some extent before the heart. 

Heart. — The most striking peculiarity of the infant's heart is that it is 
less covered by the lungs than in adult life. Together with the thymus 
gland it forms a solid mass from the posterior mediastinum to the sternum, 
pushing the lungs far apart. It is to be noticed, however, that the pleural 
cavities extend as far forward as in the adult. The relations of the heart 
to the chest walls are curious in the infant, for these anterior walls are, as 
already stated, high in relation to the spine, yet the heart itself is high in 
relation to the walls. At least the upper half of it is so. With regard to 
the apex and the lower borders the relations are less certain. We usually 
find the impulse of the heart rather higher and nearer to the mammary 
line in the infant than in the adult. The weight of the heart at birth is 
20.6 grammes (about § ounce), according to Boyd, and its proportion to 
the rest of the body is largest at about the time of birth. 

Common Carotid Artery. — The common carotid artery has in the new- 
born half the length of the descending aorta, but this proportion is much 
lessened at a more advanced age, when the vertebral column increases in 
length. 

Veins. — According to Jacobi, there are one hundred valves in the veins 
of the lower extremities of the new-born. 

Pulmonary Artery. — The pulmonary artery also, as stated by Jacobi, 
is from two to four centimetres (three-fourths to one and five-eighths 
inches) larger than the descending aorta. 

Lung. — Anatomically on the right side the eleventh rib behind marks 
the lower border of the lung, while it descends as low as the twelfth rib on 
the left side. In front the lung extends to about the fourth or fifth rib on 
the right side and the sixth rib on the left side. The lung at birth is charac- 
terized by its embryonic type. The infant's lung represents an interme- 
diate condition of growth, which illustrates the gradual change from the 
foetal to the adult condition. (Figs. 5 and 6, Northrup.) 

According to Northrup, if we examine the lung of a five months' 
foetus it is found that the bronchi constitute the entire respiratory tract 
thus far developed. At the terminal end of the bronchi there are bud- 



Fig. 5. 




«r pp* 



Section of t'cetal lung at 5 months, showing development of bronchi ; no alveoli. 



Fig. 6. 




W 






Section of infant's lung at 10 months, showing increased proportionate amount of parenchyma 
in comparison with the foetal condition ; distended alveoli. 



THE INFANT AT TERM. 33 

like dilatations, which are the rudimentary air-spaces. Between these 
dilatations, and separating them from each other, is loose, delicate con- 
nective tissue, which makes up the remaining bulk of the lung, so that 
what subsequently becomes the alveoli is about equal in extent to the 
previous bronchial development. This rudimentary air-space is destined 
to enlarge, subdivide, and finally, in early adult life, to occupy all the 
available room among the bronchial branches. The loose connective 
tissue becomes finally thin, dense bands constituting the stroma. This 
serves to distribute the vascular net-work, and upon this are laid the 
close-fitting epithelial linings of the air-spaces. In foetal life the mucous 
membrane lining the bronchial tubes is loosely attached to the muscular 
walls, and is commonly seen lying in wavy folds within the contractile 
ring, where the same delicate connective tissue loosely holds the growing 
tissues together. As has been said, the aerating portions of the lungs 
develop as bud-like dilatations at the tips of the smallest bronchi. These 
dilatations in the course of their development extend into the stroma. 
The epithelium, changing from the columnar type characteristic of the 
smaller bronchi, covers the newly made walls with flat respiratory epi- 
thelium. At birth the loose connective-tissue stroma of the foetal lung of 
five months has been condensed into rather thick alveolar walls. Another 
feature of the child's lungs as contrasted with those of adults is the be- 
havior of the blood-vessels. Being loosely restrained in the walls, they 
easily become distended and tortuous and encroach upon the cavity of the 
alveoli. With small alveoli, thick walls, and abundant distribution of 
vessels, it is easy to understand how, in hypostasis, distention of the ves- 
sels may be an important factor in displacing the air in feeble subjects 
with weakened respiratory vigor and partially obstructed bronchi. 
Finally, the lung of the infant differs from that of the adult mainly in 
the following respects. Proportionately the extent of the bronchial tubes 
is greater than that of the air-spaces. The connective-tissue stroma is 
likewise in greater abundance and tends to cellular proliferation. The 
submucous connective-tissue of the bronchi is loose and more abundantly 
supplied with nuclei, and its vessels are held more loosely. The cells 
lining the air-spaces form a continuous layer. The alveoli are small, 
their epithelium proliferates abundantly, and the absorbents accomplish 
their work slowly, the blood-vessels playing a more important role. 
These facts are to be borne in mind in connection with the bronchial 
lesion which forms so important a part of bronchopneumonia. 

ABDOMEN. — The essential differences between the abdomen of the 
infant and that of the adult are the great size of the liver in the former, 
and also the relatively large size of the kidneys and the suprarenal capsules. 

The liver, especially on the right side of the abdomen, encroaches on 
the space which is later occupied by other organs. Its relative weight to 
that of the whole body at birth is about 1 to 18. (McClellan.) 

On the left side of the abdomen these conditions are not of much 



34 



PEDIATRICS. 



Fig. 




importance, but on the right, occurring as they do in connection Avith the 
great size of the liver, the large kidney occupies a lower position, and 
thus still further curtails the free space in the right flank. Viewed from 

the stand-point of the adult condition the 
relations are, as has been pointed out by 
Henke, much more peculiar on the right 
than on the left. The kidney as a whole 
is lobulated, as seen in Fig. 7. 

Uric Acid Infarction. — At birth a 
prenatal condition, represented by an 
Lobuiated kidney, natural size, infant orange or a light red colored deposit near 

three days old. S E marks the suprarenal the pyramids ill the straight tubules of the 
capsule. Warren Museum, Harvard L>ni- , 

versity. kidney, exists normally. This condition 

is called the uric acid infarction, and the 
deposit consists of urate of ammonium, amorphous urates mixed with uric 
acid crystals, and some epithelial cells. (Plate III., 3 and 5, facing page 84.) 

The suprarenal capsules at birth quite cover and surmount the kid- 
neys, as seen in Fig. 7. 

Stomach. — The stomach at birth is remarkably small, and more tubu- 
lar than in the adult, the fundus being but slightly developed. It is con- 
sequently even more vertical than in the adult, for it is the enlargement 
of the greater cul-de-sac that makes the obliquity of the axis pronounced. 

Fig. 8, representing a stomach taken from an infant three hours old, 
shows very well the organ at birth. Its capacity was 25 c.c. (■§- ounce). 
The weight of the infant was 2500 grammes (5J pounds). Although the 
weight was below that 

of the average infant FlG - 8 - 

at birth, the stomach 
was of about the aver- 
age size, as was shown 
by its gastric capacity. 

Duodenum. — The 
duodenum, in the 
adult, has of late usu- 
ally been described 
as ring-shaped, but 
it generally presents 
pretty well marked 
angles, which divide 
it into a horizontal 
part running back- 
ward, a descending 
one along the right 
side of the spine, a transverse one crossing usually the third lumbar 
vertebra, and, finally, an ascending part along the left of the spinal col- 




stomach, natural size. Infant three hours old. 
Warren Museum, Harvard University. 



THE INFANT AT TERM. 35 

umn, which brings the end to about the same level as the beginning. 
Sometimes the last two parts are represented by a single one running 
obliquely upward to the left, in which case the duodenum is called V- 
shaped. The first horizontal portion is often somewhat dilated, and its 
walls are smooth, the folds beginning usually with the descending por- 
tion. The walls of the duodenum, just beyond the pylorus are lined by 
a continuous layer of Brunner's glands, which extends through the first 
part, becoming more or less broken up towards the end. In the infant 
the shape of the duodenum, as shown by plaster casts (specimens in 
Warren Museum), is more nearly that of a ring, the two lower angles 
being rounded off. A constriction is often (perhaps usually) seen at the 
junction of the first and second parts, but D wight's casts of the infant's 
duodenum do not show the folds, which are very striking in the casts 
taken from adults. That is to say, those of the infant show a few deep 
cuts into the cast instead of a great many near together. I have seen the 
folds, however, very richly developed in an infant of three weeks. In 
one case, that of a female six weeks old, Dwight found the duodenum of 
the V-shaped pattern, and, what is more remarkable, after it had passed 
the gall-bladder it was surrounded by peritoneum so as to swing freely as 
a loop suspended from the posterior abdominal Avail. As to Brunner's 
glands, a few observations on young children have suggested that they 
were rather less developed relatively than in the adult, but this may not 
always be the case. The duodenum has been compared to a trap, its 
ends being always higher than its middle, which is thus fitted to retain 
the fluid poured into it from the liver, the pancreas, and its own glands, 
besides that which it receives from the stomach. 

The number and size of the folds and the shape of the duodenum in 
the adult would tend to delay the passage of its contents through it, and 
thus it also prevents the passage of gases from the small intestine upward 
into the stomach. If it be true that in the infant the system of folds 
is less developed, its passage would be relatively easy, which with a fluid 
diet seems desirable. 

Intestines. — From what we know of the development of the intestinal 
tract, which was at first merely a loop loosely attached to the posterior 
abdominal wall, it is natural to expect that in the infant and young 
child it should be less fixed than in adult life ; and this is, in fact, 
the case. The difference is most striking in the large intestine, and is 
shown particularly in the caecum, ascending colon, and sigmoid flexure. 
That this condition gives rise to dangers is evident, and I should say that 
there is a strong probability that the cases of infantile intussusception 
which occur with unusual frequency during the middle of the first year 
may arise from this anatomical peculiarity, and this makes a thorough 
knowledge of the anatomy of the intestine important. In the foetus at 
full term the length of the intestine, and especially of the colon, is singu- 
larly constant. 



36 PEDIATRICS. 

Small Intestine. — The average measurement of the small intestine in 
infancy is 287 cm. (9 feet 5 inches). The variation may amount to 61 
cm. (about 2 feet). 

Large Intestine. — The large intestine at birth, according to Treves, 
measures 56 cm. (about 1 foot 10 inches). So regular are these measure- 
ments that the greatest variation that I have met with in the colon was as 
little as 12.7 cm. (about 5 inches). 

Sigmoid Flexure. — But little of the sigmoid flexure is found in the 
pelvis at birth. 

PELVIS. — The small size of the infant's pelvis is to be noted also as 
the cause which, to a greater or less extent, forces the pelvic organs of 
later life into the abdomen during infancy. 

BLADDER. — In the infant the bladder is practically wholly an ab- 
dominal organ. 

UTERUS.— At birth, part of the uterus is above the brim of the 
pelvis. 

TEMPERATURE. — The temperature at birth is slightly higher than 
a few days later. It is about 37.2° C. (99° F.). 

PULSE. — The pulse varies from 120 to 140 to the minute at birth, 
and it is at times irregular, especially during the first few hours. 

RESPIRATION. — The respiration is about 45 to the minute, but it is 
of a very irregular type, and the rhythm changes continually. The 
breathing is superficial, sometimes quick, and again dying away so as to 
be almost imperceptible. This condition, if occurring in an older child, 
would be a symptom of grave disease, but may be said to be normal at 
birth. The rate may be much quicker than 45, and I have frequently 
observed it as high as 60 or 70. 



AVWL_ 



Fig. 9. 




Quick Pause Slow Quick 

Respiration at birth for one-fourth minute. Awake, but quiet. 

HEIGHT. — The new-born infant's average height is in the male about 
49.5 cm. (19{ inches) ; in the female 48.5 cm. (19 J inches). 

WEIGHT. — The weight of the male infant is usually rather greater 
than that of the female. The average weight in a large number of cases 
showed that of the male to be 3250 grammes (7| pounds), while that of 
the female is 3150 grammes (7 pounds). Parker, in a careful examination 
of 170 infants at birth, of whom 89 were males and 81 females, found 
that the average Aveight of the males was 3520 grammes (7 j pounds), 
while that of the females was 3290 grammes (7 \ pounds). There is, 
then, a certain amount of latitude to be accepted in this question of weights. 



THE INFANT AT TERM. 37 

The weight, however, has so close a connection with the vitality of the 
infant, that although we often see infants of light weight vigorous and 
thriving, and those of considerable weight failing to gain, yet as a general 
index of vitality the weight is a valuable starting-point and guide for our 
treatment. Rules and averages of this kind are not to be depended upon 
absolutely, but simply represent conditions which with other important 
factors aid in solving the problem of vitality. 

VITALITY. — In the early hours and days of existence it is the dis- 
turbance of the equilibrium of the infant's vitality which is especially to 
be feared and combated rather than the specific morbid processes of later 
childhood. We should therefore in each infant carefully determine the 
degree of inanition which we are called upon to deal with at this period 
of life, and I have personally found it useful, as shown in the following 
table, to divide the weak and strong infants into groups according to their 
weights, allowing a somewhat lighter weight for girls than for boys. 

TABLE 1. 

Relation of Weight to Vitality. 

Groups. Weight. Vitality. 

1 2000 grammes (about 4^ pounds) Very low. 



2500 


" 5£ 


3000 


" 6£ 


3500 


" 7£ 


4000 


" 8 


4500 


" 9 



Low. 
Fair. 

Normal. 
High. 

Very hi^h. 



HANDS. — At birth it is quite remarkable to find with what manifest 
strength the infant can grasp your finger. The nails are well formed. 

FEET. — A very important part of the infant's anatomy is the foot. 
The later researches of Dane have shown that the foot of the new-born 
infant is not normally flat. On the contrary, the bones are so arranged as 
to form an arch that is even higher in proportion to its length than that 
found in adult feet. The flat appearance is caused by the presence in the 
sole of a very large amount of fat tissue and the greater proportionate 
size of the adductor pollicis muscle. 

BONE MARROW. — At birth, and in the early months of life, the 
marrow of the bones is red, as shown in Plate II., facing page 80. 

The red color caused by the numerous injected blood-vessels is more 
intense at the central portion of the section of this bone than at the 
periphery or towards the ends. 

FUNCTIONS. — Voice. — The normal infant at birth should present a 
developed voice, and should cry vigorously, thus assisting the lungs to 
expand and the new circulatory mechanism to be well started. 

Sight. — Although the eye is anatomically developed and is sensitive to 
light, and although the visual perception is also possibly developed, yet 
there is still a lack of power to interpret the images perceived. 



38 PEDIATRICS. 

Hearing. — The auditory sensations appear to be rather dull during the 
first few days of life. This is possibly due to the absence of air from the 
tympanum and a tumid condition of the tympanic mucous membrane. 

Touch. — The sense of touch is well developed. 

Taste. — The sense of taste is well developed. 

Smell. — The sense of smell is probably well developed ; but this is 
still a matter of dispute. 

Sebaceous Glands. — The function of the sebaceous glands is fully de- 
veloped at birth. 

Lachrymal Glands. — The secretion of the lachrymal glands is not de- 
veloped at birth. The new-born infant does not shed tears, a fact of some 
clinical consequence in connection with the prognosis as to the convales- 
cence of disease in the early days of life. 

Sweat Glands. — The function of the sweat-glands is not developed at 
birth as a rule, but according to my observations perspiration in certain 
individuals certainly occurs at a much earlier period than is usually sup- 
posed. I have seen an infant, premature at the seventh month, perspire 
freely one week after it was born, and in a number of individuals this 
function must exist in the early days of life. 

Salivary Glands. — The salivary secretion is not fully established at 
birth, and consequently the mucous membrane of the mouth is compara- 
tively dry. The peculiar whitish color of the young infant's tongue is caused 
by the epithelium not being washed away by the saliva to the extent that it 
is after the later development of the function of the salivary glands. The 
amylolytic function of the saliva is very slightly present at birth. The 
amylolytic action is indeed so insignificant that it merely shows us that 
the function of the salivary glands in the early months of existence is only 
partially developed and certainly should not be called into use. 

Pancreas. — The amylolytic action of the pancreatic secretion at birth 
is probably not all developed. The fat digestion is fairly developed at 
birth. The proteid digestion is fairly developed, but not fully. 

Bile. — According to Foster, " the excretory functions of the liver are 
developed early, and at about the third month of intra-uterine life bile- 
pigment and bile-salts find their way into the intestine. A quantity of 
bile secreted during intra-uterine life accumulates in the intestine, espe- 
cially in the rectum, and forms, together with the slighter secretion of 
the rest of the canal and some desquamated epithelium, the meconium. 
The distinct formation of bile is an indication that the products of foetal 
metabolism are no longer wholly carried off by the maternal circulation, 
and that to the excretory function of the liver are now added those 'of 
the skin and kidney." 

BLOOD. — It is impossible by the methods at present known to deter- 
mine exactly the total amount of blood in either infant or adult, but, while 
the adult's blood is approximately about one-thirteenth of the entire 
weight of the body, the infant's is represented by only one-fifteenth. A 



NORMAL DEVELOPMENT. 39 

full description of the normal blood in infancy and childhood will be 
found on page 874. 

LYMPHATIC SYSTEM. — The lymphatic system is very active at 
birth. 

URINE. — The amount of urine secreted during the first two days of 
life is very small, and its specific gravity is about 1010. The kidney 
shows the condition of the uric acid infarction, and it is not infrequent to 
find the napkins stained with a uric acid deposit, such as is represented 
in Plate III., 3 and 5, facing page 84. 

INTESTINAL DISCHARGES. — Unless a discharge of the contents 
of the intestine has taken place during the delivery, as is so often seen in 
breech presentations, it occurs immediately or very soon after birth. 

Meconium. — The discharge which first comes from the intestine is 
called the meconium. It is inodorous, viscid, slightly acid, and of a 
brownish-black color, such as is represented in Plate III., facing page 84. 
The meconium contains mucus, epithelium from the intestinal mucous 
membrane, epidermal cells, hairs, and fat-drops from the vernix caseosa 
which have been swallowed with the amniotic fluid from time to time, 
It also, according to Vierordt, contains the constituents of the bile, and its 
total amount is from sixty to ninety grammes (two to three ounces), of 
which the solid part forms about twenty per cent. The intestinal con- 
tents at birth are sterile. 

IV. NORMAL DEVELOPMENT. 

In order to differentiate normal from abnormal conditions in the 
growing infant and child, the different stages of development correspond- 
ing to the various ages should be studied. 

CORD. — By a process of disintegration the cord at about the seventh 
or eighth day separates from the living tissues around the umbilicus. A 
certain amount of bleeding may take place at the point of separation, but 
this is usually very slight ; it may, however, be the beginning of one of 
the most serious forms of disease in the new-born, umbilical hemorrhage. 
The umbilical depression is well marked, even when the infant cries, and 
this normal anatomical condition following the separation of the cord can 
thus be distinguished from the umbilical prominence representing cases 
of umbilical hernia. 

SPINE. — The time of consolidation of the bodies of the vertebrae is 
not accurately known, but it may be roughly stated to begin in the third 
year, and, probably, to end in the seventh. A large number of observa- 
tions must still be made before the various stages of ossification can be 
determined. The statements regarding this point are copied from one 
book to another, and are often quite imaginary. 

The union of these chief centres to form the bodies of the vertebrae 
begins in the lumbar region, and is first completed there. This union, 



40 



PEDIATRICS. 



however, had not taken place in the dorsal and cervical region of the 
child said to be three years old, used for "The Frozen Sections of a 
Child 1 ' (Dwight). On the other hand, in a girl of five or six years, figured 
by Symington, the process was found to be hardly finished in the lumbar 
region, and higher up it seemed about the same as in the younger child. 
The process of union of the laminae is probably completed in the first few 
months of life. 

Length. — The following table shows the results of the measurements 
of the spines of children by various authorities. There is a remarkable 
uniformity of observations by different men in spite of the errors incident 
to the personal equation of the investigators and the individual variation 
which doubtless exists. The relative length of the dorsal (more properly 
the thoracic) region is shown to be somewhat greater than that of the 
adult ; still it appears that after the age of five or six the proportions 
are not far from those of after-life. 

TABLE 2. 

Length of Spine to Sacrum. 



Absolute Length, in Millimetres. 


Relative Length. 
Total = 100. 


Age. 


Observer. 


Cervical. 


Dorsal. 


Lumbar. 


Total. 


Cervical. 


Dorsal. 


Lumbar. 


3 months .... 
6 months .... 
6 months .... 

10 months 

2 years, boy. . 

2 years, boy. . 

3 years, girl. . 

4 years, girl. . 

5 years, boy . . 

5 years, boy . . 

6 years, boy . . 
9 years, girl. . 

11 years, boy. . 
13 years, girl. . 
16 years, girl. . 

16 years, girl. . 

17 years, girl. . 


Rasenel .... 

Aeby 

Aeby 

Dwight .... 
Rasenel .... 

Aeby 

Dwight 

Aeby 

Symington . 

Rasenel 

Symington . 

Rasenel 

Aeby 

Symington . 

Aeby 

Aeby 

Dwight 


50 

52.5 

53.5 

61 

70 

79.5 

78 

79.9 

80 

80 

80 

85 

91 

95 
100 
107.5 
113 


100 

103 

107 

125 

140 

153.5 

162 

162 

170 

180 

175 

195 

218.7 

220 

221.9 

229.5 

250 


58 

60 

61 

77 

90 

98 
101 
103.3 
104 
135 
106 
150 
153.5 
136 
151 
152.5 
161 


208 

215.5 

221.5 

263 

300 

331 

341 

345.2 

354 

395 

361 

430 

463.2 

451 

472.8 

489.5 

524 


24 

24.3 

24.1 

23.2 

23.3 

24 

22.9 

23.1 

22.5 

20.3 

22.2 

19.8 

19.7 

21.5 

21.1 

21.9 

21.5 


48.1 

47.5 

48.6 

47.5 

46.7 

46.4 

47.5 

46.9 

48 

45.6 

48.5 

45.4 

47.2 

48.7 

46.9 

46.9 

47.7 


27.9 

27.8 

27.5 

29.2 

30 

29.6 

29.6 

29.9 

29.4 

34.2 

29.3 

34.9 

33.1 

29.1 

31.9 

31.1 

30.7 



The figures to the left Of the double line in the table express the abso- 
lute length of the different portions of the spine, in millimetres. 

Those to the right are the same figures reduced to terms of 100, 
within a fraction. 

Flexibility. — The spine is very flexible at birth. This flexibility be- 
comes less as the infant grows older. 

In the cadaver of a female child of ten months it was found that ex- 
tension was no longer so free as in the earlier months, and it . required a 
strong pull to make the head touch the nates. The dorsal region, how- 
ever, could still be made concave behind. Flexion was free, especially in 



NORMAL DEVELOPMENT. 41 

the lower part of the lumbar region, where the pelvis and legs could be 
swung forward. On rotation the head could be turned through an arc of 
90° without using the joint between the atlas and the axis. In a male 
child of the same age, extension of the spine was found to be still more 
restricted. 

Curves. — At birth there are no natural curves except the sacral in 
the infant's spine. An important factor in the production of the curves 
in the cervical and dorsal regions is probably the pull of the muscles. 
The dorsal curve seems to be a permanent condition of a part of the 
general curve of the body. As soon as the muscles of the back of the 
neck contract so as to raise the head from the chest, the front of the 
neck will be convex, and finally this becomes the habitual position. As 
Symington has pointed out, however, this cervical curve is never, prop- 
erly speaking, consolidated, for it can always be obliterated by a change 
of the position of the head. The production of the lumbar curve is 
more complicated. If an infant be laid on its back on a table, the 
knees are raised and fall apart; if they are brought together and for- 
cibly pressed down, the lumbar region will spring up from the table 
and the beginning of a lumbar curve will appear. It is supposed that 
this is caused by the shortness of the ilio-femoral ligaments, which, when 
the thighs are brought down, flex the pelvis, throwing the promontory of 
the sacrum forward. As the child begins to stand, the body is inclined 
forward, and when this is straightened by the muscles of the back the 
same thing occurs, for of course it is unimportant whether the legs are 
extended on the trunk or the trunk on the legs. 

This curve, therefore, is first observed when the child is one or two 
years old, but it is not until some time later that it is habitually present. 
It can be obliterated up to adult life. The tonicity of the muscles has a 
great deal to do with retaining the curves of the spine and with limiting 
its movements. The importance of the muscles in distortions is very 
great. The spine of the child is flexible in many ways, and the unruly 
pull of a muscle may easily produce a lasting effect. Not only should 
the muscles have strength enough to maintain the figure without conscious 
effort, but their action should be symmetrical on both sides, and should 
also have a proper relative force before and behind. The importance of 
light gymnastic exercises is now generally understood. 

Fig. 3, page 23, represents the curves of the infant's spine at birth 
and also at different ages up to the period of standing. 

Surface Anatomy. — The surface anatomy of the spine is of much im- 
portance in the child. In the infant, except perhaps in the neck, the back 
is rounded ; later it is more flattened, and the line of the spinous pro- 
cesses is rather prominent. When we examine the dissected spine from 
behind we find it very different from that of the adult. In the infant the 
laminae look more directly backward, and their presence in the median 
line is marked by knobs and ridges very different from the spine of the 



42 PEDIATRICS. 

adult. Up to a year, or perhaps eighteen months, the proportions are 
not very different, but the spine at three years shows that a great change 
has occurred, for the spinal processes now stand out in a prominent row, 
and present very nearly adult proportions. The greatest difference is in 
the dorsal spines, which are relatively broader at their points and less 
gracefully drawn out than in the adult. The bodies of the vertebrae still 
remain less deep, and therefore the relative positions of the spines and 
bodies show less difference than might be expected. At six or seven 
years the spine has made still further progress towards the adult propor- 
tions. By the end of the second year the back of the living child is not 
only flatter and broader (the results of continuous changes), but there is 
the appearance of the median furrow, and at five or six the differences in 
this respect from the adult are not marked. It is barely possible to count 
the spines in the infant and young child, and at three and four years it is 
not very easy, though less difficult than in the adult. 

The first dorsal spine, and not the seventh cervical, is the most promi- 
nent in that region. The atlas has no spine at all ; the spinous process 
of the axis is thick and prominent, perhaps relatively less marked in the 
child than in the adult ; the third and fourth spines are very small ; the 
fifth is not much larger ; but the sixth projects more, and the seventh is 
said to be usually the first prominent one. The relative size of the lower 
cervical spines varies considerably. The sixth may be the first to assume 
prominence, and the seventh cervical and first dorsal may exceed it but 
little. It is easier to examine a child of three years and upward than an 
adult, on account of the greater softness of the tissues, which allows us 
to feel more deeply in through the furrow of the neck, and, having recog- 
nized the axis by alternately flexing and extending the head, to count the 
cervical vertebrae in order. If it should be in any case absolutely im- 
possible to feel the third and the fourth, it is better to allow a certain 
space for them and to call the next one the fifth than to assume arbitra- 
rily that a certain one is the seventh. Confirmatory evidence may be 
gained from the height of the sternum. 

NECK.— (See also p. 24). 

Cricoid Cartilage. — Symington states that in two children respec- 
tively five and six years old the lower border of the cricoid cartilage was 
found to be at the lower border of the fifth or at the top of the sixth ver- 
tebra. The position of the head, in his observations at intermediate ages, 
in these measurements varied a good deal. In a girl of thirteen he found 
that it had reached the adult position ; that is, about on a level with the 
top of the seventh vertebra. 

Epiglottis. — Symington found also that the top of the epiglottis de- 
scends during growth from about the level of the lower border of the 
atlas to the middle of the third cervical vertebra, or even lower. 

Larynx. — This high position of the larynx would imply a greater part 
of the trachea relatively above the sternum, but this is. neutralized by the 



NORMAL DEVELOPMENT. 



43 



high position of the latter. The amount of fat in the neck makes the 
trachea less accessible. The greater distance .of the trachea from the 
surface, as it descends, and the greater danger of meeting the large arteries 
and veins above the sternum in the child, are points of anatomy so well 
known in connection with tracheotomy that it seems hardly worth while 
to dwell upon them. 

Distance from Cricoid to Sternum. — A condensation of Tillaux's 
statements of the distance from the cricoid to the sternum is given in 
Table 3. 



TABLE 3. 

Relation of Cricoid to Sternum. 



Years. 
2*- 

3 . 

4 . 

5 . 

6 . 



Distance from C 

3.5 centi 

4 

4 



icoid to Sternum, 
metres. 



'#■ 

8 , 
8*. 

9 . 
9*. 

10 . 
10*. 



4 

4.5 

4.9 

5.5 

5.1 

4.5 

5 

5.25 

5.25 

6.5 

6.5 

6.5 



It seems rather remarkable that at ten years the distance should be as 
great as in the adult, but this may be accounted for by the subsequent 
descent of the larynx, and also, probably, by its proportionate enlarge- 
ment (at least in the male) about puberty. 

The peculiarities of the relations of the top of the larynx and pharynx 
to the spine in the young child are points of much practical importance. 
The changes which occur during growth depend largely on changes in the 
base of the skull, and on the downward growth of the jaws, which will 
be considered presently. 

HEAD. — Circumference and Circumference relative to Thorax.— . 
The measurement of the circumference of the head increases very rapidly, 
and in early childhood almost attains that of the average adult's head. 

At birth the average circumference of the head is about 33 cm. (13 
inches), and the thorax 1 or 2 cm. (J or f inch) less. The following 
table shows the relative and proportional growth of the head and thorax 
up to the period of puberty. These figures represent measurements from 
somewhat over one hundred cases. It will be seen that the circumference 
of the thorax has become equal to that of the head by the end of the 
first year ; though in exceptional cases the thorax surpasses the head at a 



44 



PEDIATRICS. 



much earlier period, and I have even seen it exceed the circumference of 
the head at birth. Again, in some cases, the head, even in the second 
year, remains larger than the thorax. After the second year, the meas- 
urements of the head vary very little, and depend more upon the individual 






Five Weeks. 



Fig. 10. 

Five Months. 



Head 



Twelve Months. 







Relative circumferences of head, thorax, and abdomen. 



than upon the age ; the thorax, on the contrary, increases year by year. 
The measurements which are given were taken almost entirely from 
boys. Girls, for the same age, show a proportionately smaller circum- 
ference for the thorax and also for the head. 



NORMAL DEVELOPMENT. 45 

TABLE 4. 
Circumferences of Head and Thorax from Birth to Thirteen Years. 
Age. Head. Thorax. 

Birth 33 cm. (13 inches) 31 cm. (12^ inches). 

5 weeks 38 cm. (15 inches) 36 cm. (14J inches). 

5 months 42 cm. (16£ inches) 41 cm. (16J inches). 

9 months 45.5 cm. (18 inches) 43 cm. (17 inches). 

1 year 45.5 cm. (18 inches) 47.5 cm. (18| inches). 

2 years 48 cm. (19 inches) 51 cm. (20£ inches). 

3 " 51 cm. (20£ inches) 55 cm. (21| inches). 

4 " 53 cm. (21 inches) 54 cm. (21J inches). 

5 « 53 cm. (21 inches) 54 cm. (21f inches). 

6 " .52 cm. (20J inches) 55 cm. (21§ inches). 

7 " 54 cm. (21^ inches). 54 cm. (21^ inches). 

8 " 53 cm. (21 inches) 59 cm. (23| inches). 

9 " 54 cm. (21^ inches) 61 cm. (24 inches). 

10 " 53 cm. (21 inches) 62 cm. (24J inches). 

11 " 56 cm. (22J inches) 63 cm. (24| inches). 

12 " 53.5 cm. (21J inches) 63 cm. (24| inches). 

13 " 54 cm. (21^ inches) 66 cm. (26 inches). 

The series of circles on page 44, representing the circumferences of 
the head, thorax, and abdomen, shows in diagrammatic form what may 
be expected as to the relations of these parts of the child in the first 
year. 

No especial significance need be given to the circumference of the 
abdomen in this connection beyond what has been previously said con- 
cerning the liver, as its measurements, of course, vary very much normally 
according to the degree of distention present. 

Fig. 10 shows that, although there is great activity shown in the 
growth of the head, this activity is still greater in regard to the thorax. 

Fontanelles. — The posterior fontanelle, although ordinarily quite per- 
ceptible at birth, soon disappears, either from overlapping of the bone or 
from a permanent closure, and is usually imperceptible by the sixth week. 

The anterior fontanelle seems to grow larger as the infant grows older, up 
to about the ninth month ; this point is, however, disputed, and the increase 
may be apparent rather than real. It also seems to remain stationary, 
or almost so, from the ninth to the twelfth month, and then decreases 
slowly. It should be closed by the nineteenth to the twentieth month. 

Face and Cranium. — The proportion of the face to the cranium in 
infancy is as 1 to 8. Froriep has also made observations on this point 
in older children, and finds the following proportions : 

TABLE 5. 

Proportions of Face to Cranium. 

Age. Face. Cranium, 

Early infancy 1 to 8 

2 years 1 to 6 

6 years , 1 to 4 

10 years 1 to 3 

Adult female 1 to 2\ 

Adult male 1 to 2 



46 



PEDIATRICS. 



The small size of the facial portion of the skull in infancy and early 
childhood is shown in Fig. 12, page 49, of the infant at birth and at three 
years, and also in Figs. 28 and 29, facing page 86, of the infant at birth 
and at nineteen months. 

Fig. 11. 




Infant skull, natural size. Anterior fontanelle 4X3 cm. 
Warren Museum, Harvard University. 



As the child develops, very important changes occur in the base of 
the skull, one of the greatest of which is the downward growth of the 
face. Originally the base of the skull is practically flat. The sudden rise 
of the basilar process in front of the foramen magnum, the angle formed 
with it by the body of the sphenoid, and then the sharp descent of the 
vomer, are adult characteristics of which at birth there is little trace. 
The nasal cavity is shallow and relatively long, the posterior nares are 
small, and the vomer approaches the horizontal. The nasopharynx has,, 
therefore, very little height. The alveolar processes are still undeveloped,. 



NORMAL DEVELOPMENT. 47 

and the ramus of the lower jaw is very oblique, so that the cavity of the 
mouth is small. As a consequence, the larynx is placed very high up. 
One of the chief causes of its descent is the downward growth of the face. 

Brain. — Up to the seventh year the brain shows an active growth, 
and after that year increases slowly in weight. The convolutions are not 
fully developed at birth, and are gradually perfected as the child grows 
older. The various centres of the brain which gradually become so 
highly developed in later childhood have but little action, so far as we can 
judge, at birth and in the early weeks. 

Dura Mater. — An important anatomical condition in connection with 
the brains of young subjects is that the dura mater is much more adhe- 
rent to the skull, and thus presents an obstacle to the collection of extrava- 
sations between it and the bone. 

Subarachnoid Space. — The subarachnoid space usually contains a 
larger amount of fluid in childhood than in later life. 

Ear. — The osseous meatus is not developed until about the fourth 
year. In introducing the aural speculum under four years of age, the ear 
should be drawn forward and downward instead of upward and back- 
ward as in older children and adults, or the canal will be bent on itself. 

Petrosquamosal Suture. — The time at wdiich the petrosquamosal suture 
closes is not at present known. 

Nasopharynx. — According to Disse, the nasal cavity begins to increase 
in height directly after birth, and goes on pretty rapidly until the begin- 
ning of dentition, when it is slow until the second year is completed. 
After the first set of teeth are cut, the growth is rapid until the end of 
the seventh year. The increase in breadth occurs in the last-mentioned 
period, which also is the time in which the growth of the olfactory por- 
tion is most marked. Disse states that the posterior opening doubles its 
size in six months, remains stationary until the end of the second year, 
and then increases again. The following measurements were made by 
Dwight : 

TABLE 6. 

Breadth between Pterv- 

Age. Height of Posterior Nares. goid Processes at Hard 

Palate. 

About birth 6 to 7 millimetres 9 millimetres 

From 12 to 16 months 13 " 16 " 

" 12 to 18 " .....15 " 16 

" 14 to 20 " 11 " 17 

" 18 months to 3 years 15 " 21 " 

" 2 to 4 years 15 " 20 ' 

About 6 years 16 " 20 " 

7 or 8 years 20 " 22 " 

About^ 11 years 18 " 22 

17 years, female 22 " 20 

These figures show that the height does not gain the predominance 
until adult age. At the end of the seventh month the nasal cavity 
approaches the adult shape, though it seems broad in proportion, and has 



48 PEDIATRICS. 

not, of course, attained its full size. Merkol has shown that in later 
adolescence the growth of the respiratory portion takes place chiefly in 
the middle meatus. In infancy the posterior border of the vomer is very 
oblique. With the growth downward of the jaw this obliquity is much 
diminished at the age of seven or eight years. 

The change in the shape of the pharynx in the first two or three years 
is very great, and the pharynx of older children resembles more that of 
the adult than that of the infant. Indeed, at four weeks we find the tip 
of the epiglottis on a level with the lower part of the odontoid process. 

Eustachian Tubes. — The course of the Eustachian tube and the posi- 
tion of its opening undergo changes corresponding to the development of 
the nasal cavity. At birth the tube is horizontal, or nearly so. In the 
adult the cartilaginous portion slants downward. Nevertheless, the open- 
ing of the tube is opposite a higher part of the nose in the adult than in 
the child. In the foetus the opening is below the level of the hard palate, 
which it reaches at birth. Up to the ninth month after birth, according 
to Disse, there is but little change. After that time, however, the opening 
is distinctly higher than the floor of the nasal cavities. At four years, 
Kunkel found it to be three or four millimetres higher. In the adult it is 
opposite the end of the inferior turbinate bone. 

Pharyngeal Tonsil. — The pharyngeal tonsil increases after birth, and 
by the end of the first year has a length of eighteen millimetres. 

Hard Palate. — In a child of three years or less the line of the hard 
palate strikes about the middle of the basi-occipital bone. It Avould 
hardly be possible, without passing the finger round the soft palate, to 
feel much higher than the arch of the atlas. The base of the odontoid 
process would be under the mucous membrane seen at the back of the 
throat through the open mouth. The tip of the epiglottis is at the junc- 
tion of the odontoid with the body of the axis. Only the very top of the 
third vertebra could be satisfactorily explored. At six and at thirteen 
(Symington's plates) the line of the hard palate has about the adult direc- 
tion,— that is, it strikes about the top of the atlas or the basilar process 
near its beginning. In both the finger could probably examine the verte- 
brae from the first to the fourth inclusive. The atlas, however, would be 
reached with much more difficulty in the older than in the younger sub- 
ject, as the relations oft he soft palate are more nearly those of the adult. 

Mouth. — As the infant grows older the mouth becomes an organ more 
adapted for certain uses beyond that of a mere means of entry for the 
food to the stomach. 

Maxillary Bones. —The ossification of the maxillary bones begins 
early, progresses slowly, and, together with the final formation of the 
jaw, is completed at puberty. Fig. 12 represents the characteristic in- 
complete development of the ramus of the inferior maxillary bone in the 
early weeks and months of life, and its almost complete development at 
three years. 



NORMAL DEVELOPMENT. 



49 




The chief characteristic, as seen in Fig. 12, is the oblique angle which 
the ramus makes with the body of the bone at birth, and this becomes 
more evident when compared with the jaw at three years. The much 
greater proportion of the ramus to the body of the bone at three years, 
and the nearer approach 

to a right angle where Fig. 12. 

they join are noticeable. 

Teeth.— The devel- 
opment of the first set 
of teeth begins at about 
the seventh week of in- 
tra-uterine life, and, pro- 
gressing slowly, is com- 
pleted about the end of 
infancy. At birth the 
twenty embryo teeth, 
ten in each jaw, are so 
enclosed in the alveolar 
processes that nothing 
but the smooth mucous 
membrane is apparent 
on the gums above. Be- 
low, they are connected 
with the branches of the 
inferior dental nerve (an 
important clinical fact to 
be remembered) through 
openings at the bottom 
of the alveolar processes. 
When calcification of the 

neck of the tooth begins, elongation also takes place, and, as the tooth is 
enclosed in bony walls below and on the sides, it gradually grows through 
the point of least resistance, namely, the gum, which covers the top of 
the alveolar processes. The continued pressure gradually causes atrophy 
of the mucous membrane, and the crown of the tooth appears on the 
edge of the gums. The various teeth come through the gum at times 
which are regulated according to their development, that is, at times cor- 
responding to the calcification of their roots and consequent elongation. 
This process usually takes place in groups and with considerable regu- 
larity in the average normal infant. Variations, both as to the order in 
which the teeth appear and in the time of their appearance, are so com- 
mon that it seems hardly practicable to have set rules designating these 
times. The experience of different physicians seems to differ, but all 
practically are guided by very general rules. An infant may be born with 
one or more teeth. 




Skulls showing development of ramus at birth and at three years. 
Warren Museum, Harvard University. 



50 



PEDIATRICS. 



The first tooth may appear at any time during the first year of life, or 
may be delayed until the second year without any other apparent vice of 
development. In like manner, every kind of variation may be met with 
in the order in which the teeth appear, without the slightest evidence of 
any pathological condition, mental or otherwise, being found either at the 
time or later. It is therefore unnecessary to alarm the parents by stating 
that their child is abnormal because it has not cut a tooth in the first 
year. We should, however, carefully watch these children and be sure 
that their food contains the proper nutritive elements not only for their 
age> but also for their individual digestion. 

Fig. 13. 








Five periods of development in the first dentition. 

The appearance of the teeth in groups suggests certain practical divi- 
sions to determine various questions, such as the best time for weaning, or 
for vaccination. These divisions constitute the dental and interdental periods. 
In my individual experience, the first tooth appears at about the sixth or 
seventh month, though at times I find it much earlier, as at the fourth 
month, and later, as at the ninth, tenth, eleventh, or twelfth month. The 
first tooth which develops sufficiently to come through the gum is in most 
cases one of the middle lower incisors. The groups and the dental 
periods, allowing always for many variations, are as follows : 

TABLE 7. 
Temporary Teeth. First Dentition. Twenty in Number. 

Dental Periods. Groups of Teeth. 

I. 6 to 8 months 2 middle lower incisors. 

II. 8 to 10 months 4 upper incisors. 

III. 12 to 14 months 2 lateral lower incisors and 

4 first molars. 

IV . 18 to 20 months 4 canines. 

V. 28 to 32 months 4 second molars. 

20 



NORMAL DEVELOPMENT. 51 

The second set of teeth begins to replace the first at about the sixth 
year. 

TABLE 8. 
Permanent Teeth. Second Dentition. Thirty-two in Number. 

Years. Groups. 

6 4 first molars. 

7 4 middle incisors. 

8 4 lateral incisors. 

9 4 first bicuspids. 

10 4 second bicuspids. 

11 „ „ 4 canines. 

12 . . , 4 second molars. 

17 to 25 4 third molars ( wisdom-teeth). 

32 

The first four teeth of the second dentition are usually called the 
sixth-year molars. They do not replace any of the permanent teeth, but, 
the jaw having grown so as to provide space back of the temporary teeth, 
they appear back of and next to the second molars. This usually occurs 
at about the sixth year. 

In the seventh and eighth years the permanent incisors replace those 
of the temporary set. In the ninth and tenth years the bicuspids replace 
the temporary molars. In the eleventh year the permanent canines re- 
place the temporary, and in the twelfth year the four second molars 
appear. This really completes the second dentition of childhood, twenty- 
eight teeth. The remaining four molars belong to a period of adult 
growth. Fig. 14 (page 52) shows the manner in which the permanent 
teeth replace the temporary set between the ages of six and twenty-five 
years. 

THORAX. — Top of Sternum. — From the few observations which 
have been made, the top of the sternum in infancy and early childhood 
seems to be opposite some part of the first or second dorsal vertebra. 
(Dwight.) 

Diameters. — The anteroposterior diameter of the interior of the 
thorax is to the transverse diameter at three years, according to Dwight's 
"Frozen Sections,' 1 as one to two, and in a child of from five to six 
(Symington) the depth is even relatively greater. The ribs bend much 
less backward than in the adult, and the back first becomes rounder and 
then flatter. At four or five years great progress in growth has been 
made, and the infantile form of the thorax has wholly disappeared. 
Slight changes, however, probably go on for some years. 

Ossification. — Towards the end of the first year the bone-centres of 
the sternum have grown, and the sternum has gained a good deal in sta- 
bility. New points of ossification have probably appeared, but still the 
sternum is essentially cartilaginous, the bone merely consisting of islands 
in a sea of cartilage. At two years of age the manubrium and the second 



52 



PEDIATRICS. 



and third pieces are nearly ossified, but their shape is made by their carti- 
laginous borders. At three years I have twice seen the manubrium and 
the second piece of the sternum presenting- in bone their real shape, while 
the third piece was still framed in cartilage. Sometimes, however, the 
process of ossification is more backward. The ossification of the lower 

Fig. 14. 







1JUJLJJJLU 
17 to 25 years 

m 




Eight periods of development in the second dentition. 



part of the sternum is less advanced than the upper part. As to its rela- 
tive size opinions differ. Probably the individual variation is very great. 
The ribs being comparatively horizontal, the cartilages rise very little, and 
at the lower part of the chest in front they are nearly together, making 
narrow intercostal spaces, the seventh cartilages often meeting below the 
body of the sternum. In the dead body of a young child, especially if it 



NORMAL DEVELOPMENT. 53 

be emaciated, it is striking to see how, after the cadaveric rigidity has 
passed away, the sternum and cartilages, forming the front of the chest, 
fall in at the point where they join the ribs. 

Respiration. — At birth there is no decided type of respiration for the 
two sexes. As the infants, both male and female, however, grow older 
and a more equable respiratory mechanism becomes established, I have 
found that, as a rule, in the early months of life, the type of respiration 
is abdominal. Fig. 15 shows the irregular respiration of infancy. 

Fig. 15. 



AAMA 




Quick. Pause. Irregular. Pause. Irregular. 

Respiration for one-half minute in a healthy infant nine months old ; awake, but quiet. 

Diaphragm. — A limited number of observations by D wight showed the 
diaphragm to be opposite some part of a space between the lower part of 
the eighth and the upper part of the tenth vertebra. 

Thymus Gland. — The thymus is most developed in the first two years 
of life, but it persists longer than was formerly taught. During its 
greatest development it is found in the neck as well as in the thorax, ex- 
tending perhaps 2 cm. (f inch) above the sternum, which, you must re- 
member, is no small part of the surface of a child's neck. The thymus 
extends down the anterior mediastinum, lying on the pericardium in two 
long lobes on either side of the median line. The extent of these lobes 
is very variable, and the two are not usually symmetrical. I have seen 
them, even in an infant, so developed that the longer nearly reached the 
lower end of the sternum ; but it is very uncommon for it to reach the 
diaphragm. These prolongations become thinner as they descend. The 
thymus is a thick mass behind the first piece of the sternum, where it 
rests on the top of the heart against the great vessels concealing the in- 
nominate veins, more or less of the superior vena cava and the arch of 
the aorta, and extending back to the trachea. Lower down it extends on 
either side into the angle between the pericardium and the lungs, or 
rather pleurae. A section of the thymus made by DAvight was found to 
run nearly horizontally from the top of the fourth dorsal vertebra to just 
above the junction of the second costal cartilage with the sternum. 

The cavity of the thorax seems to be divided into three parts, one on 
either side of the lungs and a median one occupied by the thymus, the 
transverse part of the arch of the aorta, with the superior vena cava on 
its right, and the trachea and oesophagus behind. The area occupied by 
the thymus is very nearly equal to that of the left lung. The thymus 
reaches backward on the left of the aorta behind the level of the front of 
the spinal column. There is also what seems to be a piece of it between 



54 PEDIATRICS. 

the vena cava and the trachea. On the upper surface of the same sec- 
tion, at about the level of the sternoclavicular articulations, it is in front 
of both innominate veins and behind the right one. The lungs are pre- 
vented from approaching each other so nearly behind the manubrium as 

they do in the adult. 

Fig. 16. 




Frozen section, child of three years : RL marks right lung ; LL marks left lung ; T marks thymus 
gland ; G marks gullet ; CS marks superior vena cava ; AA marks aortic arch ; VA marks vena azygos ; 
F marks some fluid which happened to be in the right chest ; BT marks bifurcation of trachea. 

A frozen section (Dwight) of a child three years old (Fig. 16) shows 
that behind the manubrium there is much more of the thymus to the left 
than to the right of the median line, and its dulness on percussion must 
have been evident at the left of the sternum. Below it merges into the 
cardiac dulness, and no distinction between the thymus and heart is possi- 
ble by percussion. 

The theoretical results of enlargement of the thymus are very serious. 
Resting on the anterior and weaker ventricle, which is prolonged upward 
into the pulmonary artery, it may interfere with the pulmonary supply of 
blood, and by compressing the innominate veins and the superior cava it 
may interrupt the return of venous blood to the lungs. Whether or not 
it may compress the thoracic duct is doubtful, but it certainly may press 
on the trachea. 

The thymus is said often to persist for several years after puberty, but 
observations are not numerous on this point. It seems to disappear from 
the neck and from the front of the heart and to remain longest behind the 
first piece of the sternum. 

Heart. — The changes which take place in the infant's heart after birth 
are not simultaneous, which is a point to be remembered in making a 
differential diagnosis of cardiac disease during the first ten days of infancy. 
The following table states the time at which these changes should occur: 




* - 





(i ^ 



#J 



NORMAL DEVELOPMENT. 55 

TABLE 9. 

POST-INT AT AL CHANGES OF FOETAL CONDITIONS. 

Ductus Venosus. — The ductus venosus becomes a fibrous cord in the fissure of the 
ductus venosus in from two to five days. 

Eustachian Valve. — The intra-uterine function of the Eustachian valve practically 
disappears at once at birth, but its remains can be found for an indefinite period. (See 
heart dissected by Dr. F. Dexter, Pig. 17, facing page 54.) 

Foramen Ovale. — The foramen ovale usually closes about the tenth day, but the upper 
part sometimes never closes. The closed foramen ovale is seen in this same heart. 
(Fig. 17, facing page 54.) 

Ductus Arteriosus. — The ductus arteriosus is about 1.5 cm. (finch) long, has a diameter 
of about .25 cm. (| inch), and is usually, so far as being pervious to the blood is con- 
cerned, obliterated in from four to ten days. Its remains forms a fibrous cord connect- 
ing the pulmonary artery and the aorta. (See Fig. 18, facing page 54.) 

Umbilical Vein. — The umbilical vein becomes the round ligament of the liver, and is 
obliterated in from two to five days. As pointed out by Jacobi, it diners from the 
arteries very much less than is usual with the veins and arteries in other parts of the 
body. Its muscular layer is very large and strong. 

Umbilical Arteries. — The umbilical arteries in their upper parts become obliterated in 
from two to five days, forming the anterior true ligaments of the bladder, while the 
lower parts remain pervious and form the superior vesical arteries. The umbilical arteries 
are usually thick and strong, owing to the great development of their muscular layer. 

It is generally held that in the first year of life the long axis of the 
heart is more nearly horizontal than later. The apex is thought by many 
to be higher. This is true in the first few years, but somewhat later it 
may be found in the adult position, or, in cases where the lower part of 
the sternum is backward in development and the cartilages crowded 
together, it may be in a lower space than normal. It is not unlikely that 
a subsequent change in these portions of the walls would correct this. 
Thus, if in the early condition the apex were at the sixth intercostal 
space, a lengthening out of the lower end of the sternum might cause 
such a descent of the ribs as would bring it into the fifth space. 

Weight. — As shown by Boyd, the weight of the heart in proportion 
to that of the whole body does not vary much at different ages, so that 
the relative labor of the heart does not materially differ between the 
young subject and the adult. In the first few years, however, the increase 
of the weight of the heart is greater than at about the fourth or fifth year, 
and. this increase is again greater at about puberty. These are facts of 
practical importance to be remembered when we are studying the dis- 
eased conditions of the heart. 

TABLE 10. 

Weights of the Heart during its Development. [Boyd. ) 
Age. Grammes. 

At birth 20.6 

1 \ years 44. 5 

3 years 60.2 

5^ years 72.8 

10J years 122.6 

17 years 233. 7 

Figs. 17 and 18 show the heart in the early days of life. (Dexter.) 



56 PEDIATRICS. 

Blood- Vessels. — " According to a number of actual observations made 
by R. Thoma, the post-foetal growth is relatively smallest in the common 
carotid, and largest in the renal and femoral arteries. Between these two 
extremes there are found the subclavian, aorta, and pulmonary arteries. 
These are differences which correspond with the differences in the growth 
of the several parts of the body supplied by those blood-vessels. In 
regard to the renal artery and the kidney, it has been found that the 
transverse section of the former grows more rapidly than the volume and 
weight of the latter. Thus, it ought to be expected that congestive and 
inflammatory processes in the renal tissue were almost predestined by 
this disproportion between the size of the artery and the condition of the 
tissue. Moreover, the resistance to the arterial current offered by the 
kidney-substance depends also upon the readiness with which the current 
is permitted to pass the capillaries. It has been found experimentally 
that within a given time more water proportionately can be squeezed 
through them in the adult than in the child. These anatomical differences 
may therefore be the reason why renal diseases are so much more fre- 
quent in infancy and childhood from all causes, with the exception of that 
one which is reserved for the last decades of natural life, atheromatous 
degeneration." (Jacobi.) 

Pulmonary Artery. — It is doubtful whether there is any essential 
difference at different ages in the origin of the pulmonary artery. If we 
say that in the infant it is rather higher than later, we have stated about 
all that is justifiable. 

Lungs. — At what age the lungs reach their full expansion forward has 
not been determined. It would appear that it is not before five or six 
years, and it is probably still later. As the chest expands laterally the 
lungs of course increase, and the relatively greater size of the heart to 
the lung in the infant depends essentially on the size of the lungs. During 
the first year of life (according to Northrup) the alveolar walls are thick 
and their blood-vessels are held loosely. It is not until the fourth or 
fifth year that the proportionate adult development between the alveoli 
and the bronchi is attained, and the stroma has become dense and bind- 
ing, restraining the capillaries as in adult life. In infant life the underlying 
loose tissue lining the bronchial tubes gradually binds the mucous mem- 
brane to the fibromuscular wall. From this time it keeps pace in its 
growth Avith the other compact tissues, until in adult life it appears as 
dense fibrous bands. During the first two years the air-cells have not 
attained the proportionate capacity which exists in adult life, and the 
bronchial tree is still large in proportion to the dilating and multiplying 
alveoli. Again the air-spaces developed from the terminal bronchi have 
covered themselves Avith a continuous layer of flat nucleated epithelium. 
In its subsequent growth in adult life it is believed that the expanding 
alveolus does not increase its number of epithelial cells to cover the more 
extended wall, but somewhat enlarges their size, and, still further, that 



Fig. 19. 




Stomach, spleen, and pancreas at 10 months. Natural size, posterior view. S marks the spleen ; P marks 
the pancreas ; D, the duodenum. Warren Museum, Harvard University. 



NORMAL DEVELOPMENT. 57 

some of the flattened epithelium loses its nuclei and expands to form 
large, very thin plates, called respiratory epithelium. 

ABDOMEN. — Liver. — The liver is proportionately large at birth and 
in early childhood, and can be felt below the edge of the ribs in the right 
hypochondrium, its border being about 1 or 2 cm. (f to f inch) below the 
costal border in the mammillary line. 

Gail-Bladder. — The fundus of the gall-bladder is in relation to the 
surface of the body about that of the ninth costal cartilage near the 
border of the right rectus muscle. (McClellan.) 

Spleen. — There is nothing especially to be noted in the spleen in child- 
hood, as it corresponds in its position to that of the adult. According to 
Foster, the spleen grows rapidly in early infancy, but in proportion to 
that of the adult is both absolutely and relatively smaller. It is said that 
the spleen when enlarged encroaches more upon the thoracic cavity than 
in the adult, owing to the greater resistance offered by the costocolic fold 
of the peritoneum upon which it rests. In many cases of enlarged spleen 
from varied causes which I have met in infants it has seemed to me that 
the abdomen was encroached upon to a greater extent than in adults, 
and that both the physical and the rational signs of the enlarged splee 
in the thorax were relatively insignificant and often difficult to detect. 

Pancreas. — The function and the anatomy of the pancreas correspond 
very closely to that of the salivary glands. It is situated in front of the 
first lumbar vertebra, behind the stomach, and, according to the variations 
produced by age and the growth of other parts, lies somewhere between 
the umbilicus and the ensiform cartilage. 

The relative position of the spleen and pancreas to the stomach and 
duodenum is shown in Fig. 19. The organs were obtained at the autopsy 
of an infant ten months old. The spleen is behind the cardiac end of 
the stomach, and very near its extremity. The pancreas extends from 
the spleen (its tail being in close apposition to the latter organ) along the 
posterior surface of the stomach and somewhat upward to the smaller 
curvature, passing behind the duodenum and its head resting in the con- 
cavity of the duodenum. The curve of the duodenum is also clearly 
shown in the specimen. 

Kidneys. — The kidneys are lobulated at birth. This condition con- 
tinues for a long time and then disappears, the lobulation being repre- 
sented by the pyramids of Malpighi. A few years after birth the position 
and relations of the kidney approximate those of the adult (McClellan). 

Suprarenal Capsules. — The suprarenal capsules are relatively large 
in size, and gradually approach the adult proportions as the child grows 
older. 

Bladder. — Although small at birth, the bladder soon becomes capable 
of great distention. 

Symington, from a frozen section which he made in the median plane 
through the body of a child seven months old, shows the position of the 



58 pediatrics: 

bladder, which happened to be distended. It takes up, practically, the 
whole of the lower portion of the abdomen, an observation which at 
once suggests the difficulty of making a correct physical examination of 
the infantile abdomen during life, unless certain that the bladder is empty. 

The above fact was strikingly exemplified in a little girl, three years old, who 
was in my wards at the Children's Hospital. She was sent to the hospital for an ex- 
amination in reference to the advisability of an operation to remove an abdominal 
tumor. On inspection, a rounded prominence extending from the pubes to 3 cm. 
(11 inches) above the umbilicus could be plainly seen. By palpation the tumor could 
be felt extending from the right inguinal region over to the crest of the left ilium. 
The tumor was soft, elastic, and fluctuating. It was evidently not in the abdominal 
walls, but intra-abdominal. The child was said to have been ailing for over a week, 
and to have grown thin. She passed her urine frequently, but in small quantities. 
Nothing abnormal was found on an analysis of the urine. 

Suspecting a distended bladder, a catheter was introduced, and 270 c.c. (9 ounces) 
of urine were withdrawn. The tumor immediately disappeared, and the abdomen 
became soft and resonant. 

A practical lesson to be drawn from this case is, that the bladder 
should invariably be carefully examined and emptied before diagnostica- 
ting or operating in abdominal disease. I have seen a distinguished 
laparotomist neglect this precaution in a young child while operating for 
appendicitis, and on opening the abdominal cavity cut directly through 
the walls of the bladder. The urine flowing out through the wound was 
the first indication to him that he had failed to appreciate that in early 
life the bladder is essentially an abdominal organ. 

Stomach. — Many peculiarities of the digestive tract may arise from 
such causes as the different proportionate stages of development of the 
parts of the gastro-enteric tract at different ages, and to differences in 
their peritoneal attachments. The stomach grows very rapidly, and pecu- 
liarities of shape appear at an early age. I have seen a stomach of four 
and one-half months which, although small, was relatively broader than 
in the adult. The adult shape, however, is soon acquired. How perma- 
nent this may be is as yet unsettled. There is no doubt that great dila- 
tation may be induced, and it is highly probable that where too small 
quantities of food are given the normal stomach will contract. It is also 
very likely that certain shapes are acquired at a very early period. 
Dwight has shown me in a young child a well-marked antrum pylori, — 
that is, a pouch above the pylorus, which, in extreme cases, forms almost 
a separate chamber. It is evident that the clinical significance of our 
anatomical knowledge of the growth of the stomach in the first year is 
very great. This question of growth is, in fact, one of the most important 
factors in the problem of the substitute feeding of infants, and a lack of 
its thorough "comprehension often leads to most unfortunate results. 

Capacity. — There has been much dispute as to the proper method of 
determining the gastric capacity during infancy. All methods are open to 



NORMAL DEVELOPMENT. 59 

criticism, but by combining all the methods and making general deduc- 
tions we can arrive at practical conclusions concerning the size of the 
stomach at different ages. One of the methods which may be employed 
is a clinical one, and is as follows : 

A mother is selected who is young, healthy, has plenty of good milk, and who 
has a healthy infant of normal size and weight, and appetite according to its age, and 
one that is thriving, — that is, digesting well and gaining regularly about 30 grammes 
(1 ounce) a day. The infant is first carefully weighed : next it is allowed to nurse 
until it is evidently satisfied, — that is, practically, until it feels that its stomach is full. 
The infant is then weighed again, and the increase in weight denotes the gastric 
capacity in ounces of milk. Careful investigation has shown that one fluid ounce 
of milk weighs very nearly 30 grammes. Certain control experiments have shown 
that this method of determining the gastric capacity is a practical one. It is well 
known among those who deal in cattle that when fat cattle are transported long dis- 
tances, as from Chicago to New York, they are found to have lost materially in weight, 
perhaps thirty or forty pounds. If these cattle are allowed to fill their stomachs with 
water, an increase in their weight will be found corresponding exactly to the weight 
of the water which they have drunk. 

If a number of healthy infants of different ages and of average weights 
are fed and weighed in this way, we can approximately, by comparing the 
gains in weight which correspond to the same ages, determine the gastric 
capacity for each age. I should not, however, consider this by itself a 
reliable method for determining the gastric capacity, as it is open to many 
objections, which need not be discussed at present. One source of error, 
for instance, is the variation of the infant's appetite, which may cause 
either too great distention or underfilling of its stomach. Another method 
is the actual measurement of the gastric capacity at the autopsy, with 
suitable precautions to avoid over-distention. In this way it has been 
determined that the stomach grows very rapidly in the first three months 
after birth, grows slowly in the fourth month, and is then almost quiescent 
for about two months. It then begins to grow again until it has reached its 
adult size. Frolowsky's rules for determining the gastric capacity of young 
infants approximate in their results so closely my own investigations that 
I have prepared from them figures of infants 1 stomachs at different ages 
and at different periods of growth. The tracings of the stomachs are 
life-size. Frolowsky shows that the activity of the stomach's growth is 
very great in the first quarter of the first year, that it is very slight in the 
second quarter, and that it again shows a moderate activity in the last 
part of the year. He represents this activity of the stomach's growth by 
the ratio of 1 for the first week to 2J for the fourth week and 3i for the 
eighth week, while it is only 3J for the twelfth week, 3* for the sixteenth 
week, and 3f for the twentieth week. As a starting-point from which 
to calculate the above proportions I have taken the infant's stomach 
shown on page 34, Fig. 8, which is also intended to represent an infant 
of the average birth weight. 



60 



PEDIATRICS. 



Fig. 20. 

Gastric Capacity in the First Five Months of Life. 

I 




Infant 3 hours old. Capacity of stomach, 25 to 30 c.c. (f to 1 ounce). 



II. 




Infant 4 weeks old. Stomach 2% times larger than I. Capacity, 75 c.c. (2% ounces). 



NORMAL DEVELOPMENT 



61 



IIL 




Infant 8 weeks old. Stomach 3^ times larger than I. Capacity, 96 c.c. (3J ounces) 




Iniant 12 wee^s old. Stomach 3% times larger than I. Capacity, 100 c.c (3>£ ounce*) 



62 



PEDIATRICS. 




Infant 16 weeks old. Stomach 3f times larger than I. Capacity, 107 c.c. (3.56 ounces). 




Infant 20 weeks old. Stomach 3| times larger than I. Capacity, 108 c.c. (3.6 ounces). 



NORMAL DEVELOPMENT. 63 

In comparing- these measurements with actual stomachs, the gastric 
capacity as given for sixteen and twenty weeks is somewhat small. They 
are, however, extremely valuable to begin with, as it is always better to 
err on the side of giving too little food than too much. 

The gastric capacity, according to Fleischmann, is greater at the same 
age in the artificially fed than in the breast-fed infant. This observation, 
however, in all probability only emphasizes the importance of bearing in 
mind the normal gastric capacity of the different ages, and of using this 
knowledge to prevent the overfeeding which has produced so noticeable 
a difference between the sizes of the stomach in breast-fed and artificially 
fed infants. 

Since the development of the methods of substitute-feeding in connec- 
tion with milk modification, there is no reason to suppose that when the 
infant's stomach has been properly managed it is any larger than in 
breast-fed infants. 

The cause, however, Avhich produces the most uniform individual dif- 
ference in the gastric capacity at the same age is the weight of the infant. 
In general it can be said, the greater the weight the greater the gastric 
capacity. A good illustration of the correctness of this rule has lately 
come under my notice, where a breast-fed infant of twelve months with 
a stomach normal in shape presented a gastric capacity of only 90 to 105 
c.c. (3 to 3 J ounces). This capacity corresponded to its weight, 4289 
grammes (9J pounds), about the average normal weight of an infant at 
eight or ten weeks, rather than to its age, which in the average infant 
would present a gastric capacity of 240 c.c. (8 ounces). 

I have also had under my care an infant of six weeks whose general 
development and weight corresponded so closely to those of the normal 
average infant of twelve weeks that it was self-evident that the two 
ounces of food which would ordinarily have been the proper allowance, 
so far as the age was concerned, was not sufficient, and that its weight 
indicated a gastric capacity for an allowance of four ounces, which, in fact, 
it took and digested with the greatest ease, while with any amount less 
than the four ounces it was never satisfied. 

In this connection it is important to note that at autopsies in measur- 
ing the gastric capacity it should be done before the stomach is separated 
from its mesenteric attachment, as otherwise it is easily stretched by the 
fluid introduced, and will then show a greater capacity than would be 
within the normal limits during life. In looking at the following illustra- 
tions, which represent the actual sizes of a number of stomachs which have 
come under my observation, it is interesting also to note the different 
shapes which these stomachs represent, as some of them are very differ- 
ent from the usual classical figures represented in books. So far as could 
be ascertained, these shapes did not occur from any especial disease, such 
as would influence the outline of the stomach. 

On examining Fig. 8 (page 34) and Figs. 21 and 22, it is clear that one 



64 



PEDIATRICS. 



cannot always depend on an infant's weight for determining its gastric 
capacity in the early days of life. Thus, the weights of 2500 grammes, 
3000 grammes, and 4000 grammes all had the same gastric capacity of 



Fig. 21. 





Stomach of infant 2% days old, natural size. Gastric capacity, 25 c.c. Weight, 4000 grammes 

25 c.c. Again, the weight of 2700 grammes had a greater capacity, 40 c.c, 
than the weights of 3000 and 4000 grammes. One must, however, also 
allow that there might be an error in measuring the gastric capacity. 



Fig. 22. 




Stomach of infant 5 days old, natural size. Gastric capacity, 25 c.c. Weight, 3000 grammes 



No rules for growth can be deduced from this very limited number 
of cases. The significance of these figures will be understood a little later 
when the feeding of the early days of life is discussed. Fig. 24 represents 
the stomach of an infant twelve days old. It represents the usual shape 
and position of the stomach in early life, and has been distended beyond 



NORMAL DEVELOPMENT. 



(50 



Fig. 23. 




Stomach of infant 7 days old, natural size (posterior view). Gastric capacity, 40 c. c. Weight. 

2700 grammes. 



Fig. 24. 




Stomach of infant 12 days old, distended to hold 80 c.c. Natural gastric capacity , 40 c.e. 

5 



66 PEDIATRICS. 

the limit of its normal capacity to show the great elasticity of the ventric- 
ular walls already referred to. The gastric capacity was about 40 c.c. 
(1 J ounces) ; when distended it held 80 c.c. (2§ ounces). 

Fig. 25 shows the stomach, duodenum, spleen, and pancreas of a 
well-developed infant five months old. 




Stomach of infant 5 months old (posterior view). Weight, 6000 grammes. Distended to hold 225 c.c. 
Natural gastric capacity, 120 c.c. S marks the spleen ; P the pancreas ; D the duodenum. 

Fig. 26 shows the stomach of an infant seven months old and weighing 
5500 grammes (12 pounds). Its capacity is 220 c.c. (7 J ounces), which 
corresponds to its age rather than to the weight, which is that of an infant 
four months old. 

Another stomach taken from an infant also seven months old, but 
whose weight was that of an infant four months old, had a capacity of 
150 c.c. (5 ounces), Avhich corresponded to its weight rather than to its age. 



NORMAL DEVELOPMENT. 67 

Fig. 27 shows the stomach of an infant nineteen months old and 
weighing 6270 grammes (13j pounds). Its capacity is about 300 c.c. 
(10 ounces). 

According to these figures the gastric capacity in the third, fourth, and 
fifth months may appear rather small, and considerable differences will 
arise in the measurements by different observers. This, however, only 
emphasizes the fact that the problem of gastric capacity has not been 
solved by any system of measurement. When all observers have agreed 
to make use of a mathematically precise and constant pressure in measur- 
ing the stomach, we may possibly arrive at more uniform results. Even 
then the degree of elasticity will be found to differ so greatly in the indi- 
vidual stomach that most diverse measurements will result. 

There is no doubt that the value of these calculations lies in making 
us recognize evident changes in the activity of growth at certain periods, 
in making us allow that great differences arise irrespective of age and 
weight, in impressing us with the fact that the gastric capacity has been 
over- rather than under-estimated, and in insisting that more exact 
clinical observations should be employed to reinforce our anatomical and 
physiological data. 

Through the aid of a milk laboratory one may adapt exactly to the 
apparent needs of the infants, as well as to their age and weight, the 
amounts of food on which they have seemed to thrive. 

The following figures represent the average amounts of food taken at 
different periods during their first year by three hundred and forty-one 
infants. They were all well and strong, of average weight, and all were 
thriving and steadily gaining during the year. They received only stated 
amounts of food carefully ordered by prescription at the milk laboratory, 
and were watched with the greatest care to see when they evidently were 
hungry enough to have the total amount of their food increased. Of 
course the opportunity for exact work is almost unlimited where one has 
a milk laboratory at his command, and it has therefore seemed to me that 
this method of determining the gastric capacity is an unusually good one, 
and one which has never thoroughly been carried out before. The follow- 
ing case explains the significance of the general figures : 

An infant was fed with the greatest care both as to the quality and 
as to the quantity of its food. The following table represents the amount 
of food given at each meal from birth to ten months : 

TABLE 11. 

Amounts of Food in an Especial Case. 

\ ?P Cubic Centi - Ounces I A-e Cubic Centi_ Ounces 

Age. metres. ounces. A e e. metres. ounces. 

Birth 30 1 6 months 150 5 



4 weeks 45 1 h 

8 weeks 60 2 

12 weeks 75 2^ 

16 weeks 90 3 

20 weeks 1&2 4J 



o 



7 months 150 

8 months 150 5 

9 months 195 6£ 

10 months 240 8 



68 PEDIATRICS. 

This case shows the necessity for frequent and great increase of the 
total amount in the first four or five months, the comparative quiescence 
of growth in the sixth, seventh, and eighth months, and the increase again 
in the ninth and tenth months. It does not, however, correspond so 
closely to my previous results as does this table, in which averages taken 
from the three hundred and forty-one cases already referred to are given. 

TABLE 12. 

Three Hundred and Forty-one Infants fed at the Milk Laboratory. 

A e Number of Cases for Average Amount of Food at 

8 ' each Age. each Feeding. 

C.c. Ounces. 

Birth 45 29.4 0.98 

4 weeks 76 70.5 2.35 

8 weeks.... 84 96.6 3.22 

12weeks , 97 118.8 3.96 

16weeks 87 137.0 4.57 

20 weeks 86 158.4 5.28 

6 months 73 171.3 5.71 

7 months 56 185.4 6.18 

8 months 54 208.5 6.95 

9 months 45 226.2 7.54 

10 months 33 238.8 7.89 

11 months 28 242.0 8.07 

In this table the same infant has of course been recorded a number of times at different 



The whole question of gastric capacity is so closely connected with the 
subject of infant feeding that it can be spoken of in detail later, when it 
will be seen to be of infinite importance in our attempts to regulate the 
substitute-feeding of infants. 

Intestine. — Small Intestine. — During the first month after birth, it 
may be reckoned that the small intestine will grow about two feet (about 
sixty-one centimetres), and a like rate of growth may usually be recorded 
at the end of the second month of extra-uterine life ; but after that period 
its development proceeds in a most irregular manner. Thus, in a child 
of one year the small intestine measured eighteen feet (about five hundred 
and forty-nine centimetres), while in another, aged two years, the length 
was only thirteen feet eight inches (four hundred and seventeen centi- 
metres). Again, in a child aged six years the small intestine was no 
less than twenty-one feet (about six hundred and forty and five-tenths 
centimetres) in length, while in another child, eleven years of age, its 
length was fourteen feet (about four hundred and twenty-seven centi- 
metres). 

According to Treves, the great variations which appear so early in the 
length of the small intestine bear no relation to the growth of the child. 
They probably depend on the diet. Not only the quantity but the quality 
of the food is an important factor in the growth of the intestine. The 



NORMAL DEVELOPMENT. 69 

amount of residue, also, and the more or less irritating qualities of the 
food, must all have their effect. 

Peyer's patches are found very early. I have seen them at three days 
and again at thirteen days. 

In another case, sixteen months old, Peyer's patches were found, and 
one of them was five inches long. 

Large Intestine. — Treves has also observed that up to three or even 
four months the length remains the same, but that nevertheless a remark- 
able change occurs. This is that the large intestine grows at the expense 
of the sigmoid flexure, which at birth is nearly one-half of the large intes- 
tine, while at four months it has assumed about its permanent proportion. 
Treves found the large intestine to measure at one year two feet and six 
inches (about seventy-six centimetres) ; at six years about three feet (about 
ninety-one and five-tenths centimetres) ; and at thirteen years about three 
feet and six inches (about one hundred and seven centimetres). 

Ccecum and Ascending Colon. — In about thirty-five observations on 
children under four years of age, most of them new-born infants, the 
caecum was found in about thirty cases to range from the right lumbar 
region to the lower part of the iliac fossa. It was very frequently found 
at the junction of the rather vague lumbar and iliac regions. More or less 
would usually be found between two parallel horizontal lines, one at the 
level of the highest point of the crest of the ilium and the other at its 
anterior superior spinous process. In five cases the caecum was either in 
the right iliac fossa or over the true pelvis, the fact being that it was so 
free as to have no fixed position. It is comparatively recently that the 
truth has been recognized in America, England, and France that normally 
the caecum is at every age completely invested by the peritoneum, and 
that the idea that a large part of the posterior surface rests on areolar 
tissue without any intervening serous membrane is baseless, except in 
rare instances. 

In young children the ascending colon differs in some respects from 
that of the adult. Owing to the high position of the caecum, to say noth- 
ing of the relatively greater size of the liver, it is very short. There is 
no question that the ascending colon much more frequently has a mesen- 
tery than in the adult, and also that a relatively larger portion of the part 
above the caecum is also invested with peritoneum so as to be absolutely 
free. Dwight believes that the caecum of the infant and that of the young 
child are much more movable than that of the adult, and are also usually 
situated higher. 

Vermiform Appendix. — The length and direction of the vermiform ap- 
pendix are very variable. I have found it six and a half centimetres (two 
and five-eighths inches) long in a girl of thirteen days, five and three-tenths 
centimetres (two and one-eighth inches) in one of three years, eight centi- 
metres (three and one-quarter inches) in one of ten months, and seven 
and a half centimetres (three inches) in a girl eleven weeks old. It 



70 PEDIATRICS. 

would appear from Treves' s researches that the foetal shape of the caecum 
is that of a pouch hanging down from the point of junction of the small 
and the large intestine and continued into the appendix, which grows 
symmetrically from the middle. Later, however, an irregular growth of 
one side of the caecum generally leaves the origin of the appendix near 
the end of the ileum. Dwight has found that this condition usually occurs 
in the child. The position and direction of the appendix are most uncer- 
tain. It is, however, as a rule, on the posterior side of the caecum. Its 
little mesentery passes to its beginning from the caecum and is only ex- 
ceptionally attached to the walls of the abdomen or pelvis. 

The importance of the lymphatic glands about the caecum as possible 
starting-points of inflammation is very great. Tuffier states that the lym- 
phatics of the front of the caecum follow the anterior ileocaecal artery to 
empty into two glands which he has found constantly in the superior ileo- 
caecal fold, and which are very distinct in the child. The posterior glands 
are also found constantly on the posterior and inner wall of the caecum 
itself beneath the peritoneum. They usually form a group of from three 
to six. 

Sigmoid Flexure. — In some cases, according to Dwight, the sigmoid 
flexure is obviously very long, in others apparently of about the adult 
relative proportions. Even in infants, in whom the sigmoid flexure does 
not, as a rule, seem large, it often has a relatively broad mesentery, allow- 
ing free displacement. 

Descending Colon. — As is well known, the descending colon usually 
has no mesentery, but still one is often found. Lesshaft, in his observa- 
tions made on subjects of many different ages, found it once in six times. 
Dwight, in rather more than twenty infants, found a mesentery to the 
descending colon in about half the cases. Lesshaft found a mesentery 
less often in young subjects than in others. A great part of the large 
intestines in infants is less fixed than in adults. 

TEMPERATURE. — The temperature of the infant at term, although 
varying within a slight limit, is usually slightly raised. Very soon, how- 
ever, as would be expected from the tax which is immediately made on 
its vitality by so many new surroundings, the temperature falls rather 
below the normal adult standard. In about a week the normal infant has 
recovered its equilibrium, and, if its nutriment has also been properly 
adapted to its digestive power, it usually presents the average normal 
adult temperature, 36.8° C. (98.2° F.). 



TABLE 13. 

Temperature of Infant at Term. 

At birth 37. 2° C. (99° ¥. ) . 

Within an hour 36.1°-35.5° C. (97°-96° F.). 

In about a week 36.8° C. (98.2° P.). 



NORMAL DEVELOPMENT. 71 

These figures are the average of a large number, and are subject to 
great variations, as is seen on comparing them with a number of observa- 
tions undertaken at my request by Dr. C. W. Townsend at the Boston 
Lying-in Hospital : 

TABLE 14. 
Townsend' s Temperature Observations, 



Age. Temperature. 

1 day ., 37.2° C. (99° F.). 

2 days 37.3° C. (99.2° F.). 

5 days 36.6° C. (98° F.). 

5 days 37.5° C. (99.5° F.). 

6 days 37.3° C. (99.1° F.). 

7 days 37.5° C. (99.5° F.). 

7 days 37.2° C. (99° F.). 

7 days 37° C. (98.5° F.). 



Age. Temperature. 

9 days 37.4° C. (99.4° F.). 

9 days 37.1° C. (98.8° F.). 

9 days 36.9° C. (98. 4"° F.). 

10 days 37.1° C. (98.8° F.). 

13 days 37.2° C. (99° F.). 

13 days 37.3° C. (99.2° F.). 

16 days 37.3° C. (99.2° F.). 

20 days 37.3° C. (99.2° F.). 



PULSE. — The pulse in uterine life is, as a rule, somewhat higher in 
girls than in boys, the former being about 130 to 140, and the latter 120 
to 130. Anything over 130 points towards the female sex, but these fig- 
ures as a means of distinguishing the sexes before birth are not to be 
relied upon. At birth the pulse soon falls somewhat, and may be quite 
irregular. This, as a rule, is merely what we should expect would be the 
result of the sudden and great change which has taken place in the circu- 
latory mechanism, and of the additional force which the heart is called 
upon to supply when it becomes the central station from which the blood 
is propelled. The lungs also are scarcely ready to perform at once their 
function, and are often somewhat more of an obstruction than an aid to 
the blood-current. The pulse in early life, especially during the first year, 
varies very much, but, as a rule, allowing that the girl's pulse is usually 
more rapid than the boy's, the following table represents pretty well 
what may be expected in males. 

TABLE 15. 

Pulse-Rate for Males. 
Age. Pulse-Beats per Minute. 

Early weeks 120 to 140 

Until 2d year 110 

2 to 3 years 100 

5 to 8 years . . . . 90 

From the eighth year up to puberty the pulse gradually acquires the 
adult rate. The pulse in children varies greatly under the many nervous 
influences which are continually affecting it in early life. 

Townsend has also made a record of the pulses taken in the same 
infants whose temperatures were recorded in Table 14. They do not 
especially correspond with the general averages, but are what may be 
expected in cases seen at random. 



72 PEDIATRICS. 

TABLE 16. 

Toicnsend's Pulse Observations. 

Age. Quiet. Crying. 

1 day 130 158 

2 days 120 156 

5 days 152 164 

6 days 160 

6 days 152 

7 days 120 154 

7 days 160 

7 days 152 

9 days 148 

9 days 160 180 

9 days 156 

10 days 152 

13 days 136 

13 days 168 

16 days 168 172 

20 days 168 

RESPIRATION. — The respiration, although quicker in early life than 
in adults and corresponding somewhat to the pulse, assumes the equilib- 
rium of a later period of development much earlier than is found to be 
the case with the pulse. It varies with changes of temperature and with 
excitement, and has its rhythm much more easily affected by diseased 
conditions than in later life. The following table represents fairly well 
what is usually found on counting the respirations when a child is quiet : 

TABLE 17. 

Respirations. 
Age. Respirations per Minute. 

At birth 45 

Until the 3d year 1 5 to 40 

3 to 5 years 25 

The following is the record made from observations on a healthy male 
eight months old, when he was lying quietly on his nurse's lap : 

The type of respiration was decidedly abdominal. Counting the respirations by 
the rise and fall of the ensiform cartilage, which stood out quite distinctly, the respi- 
rations varied from 50 to 70 in the minute. They were, also, quite irregular, and by 
making with a pencil an upward stroke for every inspiration, a downward stroke for 
every expiration, and a horizontal line for every pause, the same lack of rhythm was 
found that appeared in the infant at term, described on page 36, and also the 
rhythm corresponding to that of the infant nine months old which is described on 
page 53. 

Townsend has also observed for me the respiration of four healthy 
infants at the Lying-in Hospital, with the following results : 

TABLE 18. 

1. Age, 1 hour Inspirations, 48 to 56. (Awake. ) 

2. Age, 2 days " 30 to 52. (Asleep.) 

3. Age, 3 days " 24, 32, 44. (Asleep. ) 

4. Age, 6 days " 28 to 40. (Crying.) 



NORMAL DEVELOPMENT. 73 

The respiration in all these cases was very irregular, and both ab- 
dominal and thoracic in type. In the baby two days old the respiration 
was chiefly abdominal. 

HEIGHT. — The average height of the male infant at term, is, accord- 
ing to a large number of measurements made by Quetelet, Vierordt, and 
others, about 49.5 cm. (19| inches). These figures correspond very 
closely to those which I have myself measured. Insufficient nourishment 
and improper food, especially as represented in rhachitic children, seem 
to retard the growth, while on the contrary, the various fevers seem to 
increase the activity of growth in length, while decreasing the total weight. 
In the first three or four months the growth is proportionally rapid to that 
in the latter part of the first year. In like manner the activity is greater 
in the first month than in the second, and in the second than in the third, 
becoming still less in the fourth, fifth, and six months. 

The average increase for the first month is about 4.5 cm. (If in. ). 

" " " " " second month is about 3.0 cm. (Uin.). 

" " " " " third to the fifteenth month is about 1 to 1.5 cm. (J to fin.). 

" " " " " first year is about 20 cm. (8 in.). 

" " " " " second year is about 9 cm. (3 J in,). 

" " M " " third year is about 7.4 cm. (3 in.). 

" " " " " fourth and fifth years is about 6.4 cm. (2$ in.). 

" " " " " fifth to the sixth year is about 6 cm. (2f in. ) 

The height is about doubled in the first six years, and at fourteen 
years the final height has usually been attained to within about one-twelfth. 
The height at different ages will be shown in comparison with the weight 
on page 81. The growth in height seems to be most active in the spring. 

WEIGHT. — In quite a number of cases it has been found that the 
careful and systematic weighing of infants gives warning of the approach 
of disease some days before any other symptoms are evident. This point 
was very clearly illustrated in a case which was under my care at the 
Infants' Hospital. The infant entered the hospital to have its food regu- 
lated. It was apparently perfectly well, but after a few days the daily 
weighing showed that it was losing. The loss of weight continued to be 
the only perceptible symptom for a number of days, when it manifested 
certain nervous phenomena and died a few days later of cerebral thrombosis. 
We sometimes notice a loss in weight preceding a chronic nutritive disturb- 
ance by several weeks, and if the coming disease is an acute one, or is of 
unusual severity, the loss is often sudden and great. The careful and 
systematic weighing of children may be of considerable value, therefore, 
in preventive medicine. Thus, if we have noticed that a child has without 
perceptible cause lost weight, we can, by guarding it from an exposure 
which in health would not be too great, prevent it from having complica- 
tions such as of digestion or from cold, and render the coming disease 
milder in its type and more readily dealt with. In a paper on the Rela- 
tion between Growth and Disease, by H. P. Bowditch, these changes in 



74 



PEDIATRICS. 



weight are especially dwelt upon, and it is apparently shown that this 
method of determining the onset of the disease is more useful in chronic 
than in acute diseases, though even in the latter class it is not impossible 
that the warning may be given in time to be of use, and to merit the term 
of ',' danger signal" which has been given to it by Bolton. Bowditch 
shows in the following table the rate of growth of a girl between two 
and three years old, and the relation between growth and disease. The 
figures represent the absolute weight of the child obtained by weighing 
in the ordinary manner, and then deducting the weight of the clothes : 

TABLE 19. 



Date. 





Weight. 


Age, in 






Weeks. 








Kilo. 


Lbs. 


107 


11.40 


25.08 


109 


11.40 


25.08 


114 


11.78 


25.91 


118 


12.25 


26.95 


119 


12.28 


27.01 


121 


11.90 


26.18 


122 


12.15 


26.73 


125 


11.80 


25.96 


126 


11.65 


25.63 


127 


11.55 


25.41 


128 


11.55 


25.41 


129 


11.95 


26.29 


130 


11.75 


25.85 


131 


11.94 


26.26 


132 


12.15 


26.73 


133 


12.20 


26.84 


134 


12.41 


27.30 


135 


11.91 


26.20 


136 


11.71 


25.76 


137 


11.98 


26.35 


138 


12.00 


26.40 


139 


12.03 


26.47 


140 


12.01 


26.42 


141 


12.34 


27.14 


142 


12.15 


26.73 


143 


12.09 


26.60 



1880. 
September 19 
October 3. . . 
November 7 . 
December 5. 
December 12 
December 26 

1881. 

January 2 . . . 
January 23 . . 
January 30. . 
February 6 . . 
February 13 . 
February 20. 
February 27 . 

March 6 

March 13... 
March 20. . . 
March 27... 

April 3 

April 10 

April 17..o. 

April 24 

May 1 

May 8 

May 15 

May 22 

May 29 



Enlarged cervical glands noticed February 5. 
Clay-colored dejections February 12-15. 



Attack of measles beginning April 5. 



Cold in the head beginning about May 22. 



An examination of this table shows that the child, having grown 
rapidly during the autumn, suddenly, and without any manifest cause, 
began to lose weight about the middle of December. This loss of weight 
was irregularly progressive until February 6, when an enlargement of the 
cervical lymphatic glands was noted, followed a week later by clay-colored 
dejections. These symptoms yielded to appropriate treatment, and the 
child again gained weight rapidly until March 27, when a sudden loss of 
weight occurred, followed by an attack of measles. A subsequent loss 
of weight in May seems to have been associated with a rather severe cold 
in the head. We have here, then, a case in which a disorder of nutrition 



NORMAL DEVELOPMENT. 75 

manifested itself by enlarged glands and by clay-colored discharges, but 
in which these symptoms were preceded for several weeks by a progres- 
sive loss of weight. It seems not unreasonable to suppose that this loss 
of weight was the first symptom of a disturbance which afterwards mani- 
fested itself by more unequivocal signs. Even in the case of the acute 
attack of measles it will be noticed that the loss of weight preceded by 
at least a week the actual eruption of the disease. It must not be sup- 
posed, however, that loss of weight in a growing child is in every instance 
a precursor of actual disease. The weight of a healthy child is liable to 
oscillation within limits which have not been accurately determined, but 
it may sometimes amount to ten or fifteen per cent, in a week. Children 
lose in weight and regain their loss in a wonderful manner, so easily are 
they affected by even slight physical disturbances, and so great are their 
recuperative powers. The weight of boys, as a rule, is somewhat greater 
than that of girls at birth, and remains greater up to the age of puberty, 
when the girl rapidly overtakes the boy, surpasses him. and becomes a 
developed woman very soon, while the boy does not become a man until 
some years after puberty. This fact is exemplified in the table on page 81, 
which shows that the girls have surpassed the boys in their height at the 
eleventh year, and in their weight at the twelfth year, when they are found 
to be taller and heavier than the boys, as is the case also in the thirteenth 
and the fourteenth year. 

The systematic and frequent weighing of infants during the first year 
of their lives I consider to be of great importance, and far more useful as a 
means for determining their nutritive condition than any other one method 
of which we know. For many years I have had the infants at the Infants' 
Hospital weighed every day as regularly as they are fed, and a glance at 
the column containing their weights in the various weeks and months 
gives information as to their general health, and serves as a guide to the 
changes which it may be necessary to make in their food. The informa- 
tion gained in this way is far beyond what the most careful physical ex- 
amination could disclose. The weight is. in fact, an index of the nutri- 
tive processes to such an extent that it is representative of the child's 
well-being, while the height gives us information rather as to its cellular 
activity. The normal average weight of quite a number of infants at 
term is for males 3250 grammes (~i\ pounds), and for females 3150 
grammes (7 pounds) ; many individual cases occur, however, where 
the weight is either greater or less than these figures, and yet the 
infant is healthy. The increase in weight is in direct proportion to 
the original weight, and if the original weight is small the gain is usually 
correspondingly small. This, however, is only a general rule, for at 
times infants of light weight are met with whose gains are remarkably 
large, and often surpass those of infants with a heavier initial birth 
weight. During the first three or four days of life there is usually a loss 
in weight, and the original weight is in a large number of cases regained 



76 PEDIATRICS. 

only in the second week. If it is not regained by the third week, we 
should consider that it is a warning that the nutrition of the infant is 
at fault, and that especial measures should be taken to increase its vitality. 
This initial loss of weight is usually designated as physiological. We must, 
not, however, be misled by this term, or place too much confidence in it, 
for, as a rule, this initial loss, which often amounts to from 270 to 300 
grammes (9 to 10 ounces) can be accounted for only partially by natural 
physiological causes. The additional loss is evidently pathological, and is 
to be so regarded, in order that we should endeavor to obviate it, and 
thus prevent imposing an additional tax on the infant's vitality at a time 
when any tax whatever should be regarded as serious. Townsend has 
made some interesting investigations on this loss of weight at the Boston 
Lying-in Hospital, which show that the infants of primiparae lose about 45 
grammes (1J ounces) more than those of multiparas ; also, deducting 45 
grammes (1J ounces) as the average loss from removal of the vernix 
caseosa, the meconium still remaining, that the loss in weight is reduced 
to 247 grammes (8£ ounces) in the infants of primiparae, and to 222 
grammes (7f ounces) in those of multiparas. The whole loss should in- 
clude the meconium, which is computed to weigh about 60 to 70 grammes 
(2 to 2 J ounces), so that a loss of from 90 to 150 grammes (3 to 5 
ounces), which includes also the urine, on the first day, can, in a very 
general way, be admitted to be purely physiological. Townsend 1 s figures 
also show that although the infants of primiparae lose more and are slower 
to recover the loss than are those of multiparas, yet after the second week 
they overtake and keep pace with the latter. The whole question is 
simply one of nutrition, it being well known that the milk of primiparae is 
somewhat longer in acquiring its equilibrium than that of multiparas, but 
that finally it is equally nutritious. It was also found that the presence 
of the colostrum corpuscles in the milk had something to do with the loss 
or with the failure to gain. Where the colostrum persisted the infants lost 
more than when it speedily disappeared. The colostrum should normally 
disappear in the first week. Where its presence is prolonged into the 
third week, the infants do not thrive. Three cases at the hospital illus- 
trated this point : all the mothers seemed healthy and had plenty of milk. 

(1) Multipara — no colostrum on third day, — infant's loss 8 ounces. 

(2) Multipara — colostrum until ninth day, — infant's loss 16 ounces. 

(3) Primipara — colostrum until thirteenth day, — infant's loss 14 ounces. 

The average loss in five infants of multiparas in whose milk the colos- 
trum was absent by the fifth or sixth day was 10 ounces. 

The whole nervous system of the young child is much more active 
and excitable than that of the adult. The brain, for instance, besides being 
fifteen times as large proportionately in the infant as in the adult, increases 
with much greater rapidity up to the age of seven years than at any other 
period. In connection, probably, with the constructive labors of the 



NORMAL DEVELOPMENT. 77 

growing tissues is the activity of the lymphatic system. The absorption 
of oxygen is said to be relatively more rapid than the production of car- 
bonic acid, — that is, there is a continued accumulation of capital in the 
form of oxygen-holding compounds. The food represents so much poten- 
tial energy, but it must be converted into tissue before the energy can be- 
come vital, and in such conversion a large amount of molecular energy must 
be expended. The metabolic activity is more pronounced in the infant 
than in the adult, and is expended not so much on the energy required in 
the external world as for the rapidly increasing mass of tissue. Another 
reason for the presence of more active metabolism in the infant than in 
the adult is the necessity of rapid molecular interchange to keep up the 
temperature. The infant having the smaller body, and yet the relatively 
larger surface (the extent of skin thus being proportionately greater), it 
loses more heat proportionately than does the adult, and thus suffers 
more easily from changes of temperature (Foster). 

Disturbances of the nutritive process from these conditions very easily 
arise, and the process of assimilation is much more important than in 
adult life, for the child's activity implies a greater consumption of nutri- 
ment in the form of food or tissue. The child's equilibrium is thus much 
more easily disturbed than the adult's, and this creates a greater suscepti- 
bility to disease and less power to resist externa] influences. This is well 
exemplified by the rule that the younger the individual the greater the 
mortality. There are three times as many deaths in the first half of the 
first year as in the second half, and a large proportion of those dying in 
the first half-year die in the first month. Of those dying in the first 
month, death occurs in a large proportion in the first week. A consider- 
able number of the deaths which occur in the early weeks of life, espe- 
cially in the first week, are from asthenia. These facts are very significant 
in connection with the child's loss of weight in the early days of life over 
that which we have just described as being physiological. Lack of suf- 
ficient nourishment and an unstable equilibrium are the factors in the 
problem which represent this early loss of weight. These conditions are 
enhanced by the state of the mother, who, exhausted by the process of 
labor, is not able to supply a food for her infant which is adapted to its 
sensitive and incompletely developed digestive function. (Evetsky). 

In addition to these manifest causes for loss of weight, we must con- 
sider that the new-born infant is much more susceptible to external im- 
pressions than when after the first weeks its various functions have 
become adapted to their new surroundings. 

The whole system is stimulated to greater activity of tissue interchange 
not only by the sudden change of temperature to which the skin is ex- 
posed, but also by the change from darkness to light, and from silence to 
a greater or less degree of sound. This transient early period of life, 
therefore, is marked by a superactive metabolism, insufficient nourishment, 
and resulting asthenic conditions which are analogous to starvation. This 



78 PEDIATRICS. 

is represented as a whole by a loss of weight evidently of a pathological 
character, in addition to that which has been described as physiologi- 
cal. One will, therefore, understand with what care the newly born in- 
fant should be protected from too great changes of temperature, too much 
light, and too much noise. The analogy of this statement is found in the 
sensitive organization and habits of the lower animals. In this way only 
can the digestive function be made to correspond to such an extent, in the 
early days of life, to the work which is required of it, as to keep the loss 
of weight within the physiological limit. Starvation, as is well known, 
proves fatal primarily not from the amount of food furnished being too 
little for the processes of disintegration, but from exhaustion of the ner- 
vous system. The endurance of the starvation is in proportion to the 
capability of resistance of the nervous tissue. This nervous tissue is so 
highly sensitive and has such great functional activity in the infant, pro- 
portionately to the adult, that it needs much more nourishment, and suc- 
cumbs much more quickly to deprivation from nourishment. Young ani- 
mals die in a very much shorter time when deprived of food than do older 
ones from this cause. It is not surprising, therefore, that when the early 
period of life is represented only by hours and days, the various disturb- 
ances which would be of minor consequence at a later period of exist- 
ence should have a decidedly pathological effect and produce a marked 
loss in weight beyond the natural physiological loss. The following case 
exemplifies the practical bearing of what has just been said. 

A male infant was born December 16 at term. It was healthy and vigorous, and. 
gave no evidence of organic disease. The mother, a multipara, strong and healthy, 
was twenty-eight years of age. Her other children were living and healthy. On the 
third day, December 19, the infant had a slight attack of icterus neonatorum, which 
disappeared in twenty-four hours. On the fifth day, December 21, the weather was- 
very cold and bleak, but the infant was taken to church and christened. The church 
was warm and the infant reasonably well protected from cold, but there was a large 
number of people present, and an unusual amount of noise. The infant, on being 
taken home, immediately began to show symptoms of asthenia, and on the following 
day was found to be cyanotic and breathing rapidly, with a subnormal temperature 
and no apparent organic disease. It died in the afternoon. The asthenia seemed to 
be produced by too early exposure to change of temperature, light, and sound. 

As a rule, the average daily gain in the first two months should not 
be below twenty grammes (two-thirds of an ounce). It has been found 
at the Infants' Hospital that if the gain is less than this the infant, as a. 
rule, is being badly nourished, is sick, or is going to be sick. There are, 
of course, exceptions to this rule, and it should be clearly borne in mind 
that observations of weight including only that of two or three days are 
very misleading, and that it is the week's weight which gives us the fairest 
idea of loss or gain. Thus, one frequently finds infants showing a daily 
gain of only five or ten grammes (one-sixth or one-third ounce), or even 
losing fifteen or thirty grammes (one-half or one ounce) on one day, 



NORMAL DEVELOPMENT. 79 

and then gaining one hundred to one hundred and fifty grammes (three 
and one-third to five ounces) on the next day. From this it will be 
readily understood that Ave should obtain from one day's observation too 
low and on the next day too high an estimate of the nutrition. By the 
end of the week, however, the weights usually equalize each other, and 
we have fairly correct figures to guide us. The following table shows 
about what would be expected of the average infant as to weight during 
the first year. Girls, as a rule, gain less than boys, but this is only if they 
are of lighter initial weight. The heavy girls make the same large gains 
as the heavy boys, but, as a rule, their initial weight is smaller than that 
of the boys, and they therefore make smaller gains. 

TABLE 20. 

General Figures of Weight. 

A Weight. Average gain per day. 

Age# Grammes. Pounds. Grammes. Ounces. 

At birth 3000 to 4000 6.6 to 8.8 

From birth to 5 months 20 to 30 £ to 1 

From 5 months to 12 months 10 to 20 J to § 

Affp Weight, 

5 Grammes. Pounds. 

At 1 year 9, 500 20. 90 

At 7 years 19,000 41.80 

At 14 years 38.000 83.60 

[The above figures are on a basis of 3500 grammes (7.7 pounds) at birth, and of a gain 
of 30 grammes per day for the first four months and 10 grammes per day for the last eight 
months of the first year.] 

Useful figures to remember are that the initial weight is doubled at five 
months and trebled at fifteen months ; also that the weight at one year is 
doubled at seven years, and that this weight is again doubled at fourteen 
years. There are, of course, both gains and losses in weight during the 
year, the weight acting as an index of the disturbances which arise. As 
a rule, what may be called the line of nutrition rises from the initial 
weight in the first week up to the fifty-second week. A uniform increase 
is, however, exceptional, on account of the many disturbances, such as 
from food, the dental periods, weaning, improper hygienic care, and dis- 
eases. 

Instances of continual weekly gains during the first year have occa- 
sionally come under my notice in both hospital and private practice, and 
the chart on page 80 gives the exact weights of a healthy male infant fed 
by a wet-nurse for over a year, and will serve as an example of the ideal 
line of nutrition. The infant was gaining so regularly that the weighing 
was omitted for several weeks, which was unfortunate, as the weights 
would probably have shown the same uniform gain. A weekly gain is 
also shown in this same chart of a male and a female infant, brother and 
sister, nursed by their mother. The double line represents the boy's 



80 



PEDIATRICS. 



weights in the first twenty-nine weeks of his life ; and the dotted line the 
girl's weight for twenty-one weeks. 



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53 B 



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1 


Date of Birth, June 21. 


Initial Weight, 4650. 




Actual Wt. 


Date of Wg. 


1 


4,500 


June 27. 


2 


4,612 


July 4. 


H 


4,916 


" 11. 


4 


5,332 


,: 18. 


5 


5,684 


" 25. 


fi 


6,004 


Aug. 1. 


7 


6,292 


" 8. 


8 


6,644 


" 15. 


9 


6,852 


" 22. 


10 


7,172 


" 29. 


11 


7.476 


Sept. 5. 


12 


7,802 


" 12. 


13 


7,994 


" 19. 


14 


8,170 


" 26. 


15 


8,362 


Oct. 3. 


16 


8,586 


" 10. 


17 


8,912 


" 17. 


18 


9,136 


" 24. 


19 


9,376 


" 31. 


20 






21 


9,968 


Nov. 14. 


22 


10,912 


" 21. 


23 






24 






25 






26 


10.912 


Dec. 20. 


27 






28 






29 






HO 






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32 






38 






34 






35 


11,680 


Feb. 20. 


36 


11,904 


" 27. 


37 


12,032 


March 5 


38 






39 






40 






41 






42 


12,544 


April 9. 


43 






44 






45 


12,640 


April 30. 


46 






47 






48 






49 






50 






51 


13,104 


June 1. 


52 

M 


13,376 
Pounds. 


" 20. 



The figures for birth, for five months, and for one year represent my 
investigations, combined with the figures which have already been shown. 
The figures for the second and third years are taken from a series of in- 
vestigations made by Peckham, of Milwaukee, in the Report of the Wis- 
consin State Board of Health for 1882. The figures for the fourth year 
are approximate averages taken from children of three and five years. 
The figures from the fifth year to the fourteenth year were taken from 
Bowditch's article on the Growth of Children, in the Twenty-second An- 
nual Report of the State Board of Health of Massachusetts. They rep- 
resent the average figures of a large number of school-children. 

In the following table the weights at birth, and in the first, second. 



PLATE II 




Icterus Neonatorum 




Red Bone Marrow 
Natural Size. 







Yellow Bone Marrow. 
3 ANatural Size. 





Erythema Neonatorum. 



NORMAL DEVELOPMENT. 



81 



and third years, were taken without clothing. The ordinary school-clothes 
were worn in the weighing from five to fourteen years. 

TABLE 21. 

Average Heights and Weights from Birth to Five Years, and of Boston School Boys and 
Girls, irrespective of Nationality, from Five to Fourteen Years. 



Boys. 


Age. 


Girls. 


Height. 


Weight. 




Height. 


Weight. 


Centimetres. 


Inches. 


Kilogrammes. 


Pounds. 


Centimetres. 


Inches. 


Kilogrammes. 


Pounds. 


49.37 


19.75 


3.25 


7.15 


Birth. 


48.12 


19.25 


3 15 


6.93 


61.87 


24.75 


6.50 


14.30 


5 months. 


59.12 


23.25 


6.30 


13.86 


73.82 


29.53 


9.54 


20.98 


1 year. 


74.17 


29.67 


9.00 


19.80 


84.55 


33.82 


13.80 


30.36 


2 years. 


82.35 


32.94 


13.31 


29.28 


92.65 


37.06 


15.90 


34.98 


3 years. 


90.77 


36.31 


15.07 


33.15 


98.27 


39.31 


17.27 


37.99 


4 years. 


97.00 


38.80 


16.53 


36.36 


103.92 


41.57 


18.64 


41.00 


5 years. 


103.22 


41.29 


17.99 


39.57 


109.37 


43.75 


20.49 


45.07 


6 years. 


108.37 


43.35 


19.63 


43.18 


114.35 


45.74 


22.26 


48.97 


7 years. 


113.80 


45.52 


21.50 


47.30 


119.40 


47.76 


24.46 


53.81 


8 years. 


118.95 


47.58 


23.44 


51.56 


124.22 


49.69 


26.87 


59.00 


9 years. 


123.42 


49.37 


25.91 


57.00 


129.20 


51.68 


29.62 


65.16 


10 years. 


128.35 


51.34 


28.29 


62.23 


133.32 


53.33 


31.84 


70.04 


11 years. 


133.55 


53.42 


31.23 


68.70 


137.77 


55.11 


34.89 


76.75 


12 years. 


139.70 


55.88 


35.53 


78.16 


143.02 


57.21 


38.49 


84.67 


13 years. 


145.40 


58.16 


40.21 


88.46 


149.70 


59.88 


42.95 


94.49 


14 years. 


149.85 


59.94 


44.65 


98.23 



FEET. — According to Dane, the pad of fat that fills the hollow under 
the bones in the infant's foot is designed to support the arch until the 
muscles are strong enough to hold it by themselves. The fat in this way 
acts as a kind of physiological flat-foot plate. 

As soon as the muscles become strong enough to protect the arch the 
pad of fat is no longer necessary, and is slowly absorbed, until by the 
fourth or fifth year the foot presents the same appearances found in the 
adult 

In a few children the pad of fat is found to be wanting, and in many 
of these cases the arch is so far obliterated that the tubercle of the scaphoid 
may even rest on the ground. These latter are the true cases of " flat- 
foot." 

BONE MARROW. — The change from the red bone marrow of early 
life to the yellow marrow of a later period begins, according to Minot, 
before birth, and progresses in each bone from the centre towards the 
periphery, or in the long bones towards the ends. 

It begins earlier in the distal bones and then goes on from bone to 
bone centripetally. Concerning the exact time when these changes take 
place very little is known, and nothing definite. Plate II., facing page 80, 
shows the red and yellow bone marrow. 

SKIN. — As the infant grows older the skin changes gradually to a deli- 
cate pinkish white in place of the decided pink of the early days of life. 



82 PEDIATRICS. 

CORD. — The cord should be carefully wrapped in antiseptic absorbent 
cotton, and no water should be allowed to come in contact with it. It 
will thus become dry sooner, and will gradually loosen and fall off. 

FUNCTIONS. — The different functions of the infant, like its physical 
characteristics, vary considerably as to the time of their development. 
It is difficult, therefore, to give exact average figures, and, in fact, my obser- 
vation of individual cases has differed so often from these average figures 
that we must allow much latitude in stating the proper time for an 
especial function to develop. 

Voice. — During the first year of its life the average infant uses its voice 
merely in crying to express its discomforts and desires. At about the 
twelfth month it usually begins to enunciate single words, and in the 
middle or towards the end of the second year it learns to form short sen- 
tences. Children vary very markedly as to the time when they really 
learn to talk connectedly, but this is usually accomplished by the third 
or fourth year, though it is somewhat later before they master the details 
of language, such as the proper use of prepositions. 

Mental Impressions. — The infant seldom smiles before the fifth or 
sixth week, the change of expression of the mouth before that time being 
usually an indication of some discomfort. In individual cases, however, 
there is no doubt that the true smile of enjoyment comes earlier, even by 
the fourth week. The infant usually does not recognize objects before 
the sixth or eighth week. Its hearing is soon established. The functions 
of touch, taste, and smell are apparently more or less developed at 
birth. 

Lachrymal Glands. — The development of the function of the lachry- 
mal glands varies considerably, but the infant will usually be found to 
shed tears when it is three or four months old. I have known tears to 
appear as early as the first month. They do not at first come every 
time the infant cries, so that a number of observations must be made 
on the same individual before deciding whether this function is present. 
I have also noticed that even older infants do not shed tears with each 
crying-spell. These facts are at times quite important to remember, as 
a suppression of the lachrymal secretion occurs where the infant's vitality 
has been profoundly affected by disease, and a return of the tears is an 
indication for giving a favorable prognosis, and often that convalescence is 
about to be established. 

Sweat Glands. — The sweat glands are developed at about the third to 
the fifth week. I have seen an infant in the second week of its life suffer- 
ing so much as to have its circulation seriously interfered with from the 
high temperature of a bath-room where it was being bathed, while the 
nurse who was bathing it was perspiring profusely, and was apparently 
perfectly comfortable. There is, however, a great variation in the time 
when these glands develop, and at times even in the second week of life 
I have noticed cases where the head was seen to perspire quite freely. In 



NORMAL DEVELOPMENT. 83 

certain individuals, therefore, the function of the sweat glands is fairly 
developed at birth. 

Salivary Glands. — The saliva is a secretion which is somewhat slow 
in being established, both in quantity and in its amylolytic property, 
There is not much flow of saliva in the infant's mouth for the first three 
or four months of its life, and even when the function of the glands has 
become so developed that the saliva appears in the mouth in abundance, 
a comparatively small amount reaches the stomach by being swallowed. 
It flows out of the mouth over the chin, and until the latter part of the 
first year, when its amylolytic action has become established, it probably 
plays but an insignificant role in digestion. The salivary secretion contains 
a certain amount of ptyalin, but its diastatic powers seem to be in process 
of development, and this should indicate to us that this function ought not 
to be forced into use in digestion until it has become much better estab- 
lished, as towards the. end of the first year. 

Pancreas. — The amylolytic action of the pancreatic secretion is but 
little, if at all, developed at birth. Towards the end of the first year the 
function seems to have become fairly well established, and to a degree which 
will not be harmed by a moderate call upon it for the digestion of small 
quantities of starch. The pancreatic power of digesting fat also seems to 
be slight in the early months of life, but to increase gradually and to be 
well established by the end of the first year. 

Bile. — The large size of the liver at birth and during infancy is well 
adapted to the great metabolic activity which is needed for the develop- 
ment of this period of life. The investigations of Jacubowitsch and 
Baginski show that the bile in children is poor in inorganic salts, with the 
exception of the iron salts. It is also distinguished by its small amount 
of cholesterin, lecithin, and fat, and the smaller percentage of its glyco- 
cholic and taurocholic acids, as compared with the bile of later life. 
The bile acids have the property of arresting pepsin digestion, and thus 
the small amount of bile acids present in infancy favor the action of the 
gastric juice, whose feeble ferment would otherwise be neutralized. The 
incomplete assimilation in infancy of very fatty food, such as creamy milk, 
is due to this lack of bile acids, for the latter aids in the emulsification of 
fat and its decomposition into fatty acids and glycerine. The feeble 
antiseptic properties of the bile in infancy and the resulting danger of 
intense fermentation of the intestinal contents is due to the lack of bile 
acids. 

LYMPHATIC SYSTEM.— The high development of the lymphatic 
system in early life is very marked. According to Foster, not only are the 
lymphatic glands largely developed and more active than in the adult (as 
is probably shown by their tendency to disease in youth), but the quantity 
of lymph circulation is greater than in later years. The observations of 
Kramstyk show that particles of fat are very easily absorbed in early 
life. Brunner's and Lieberkiihn's glands are only partially developed 



PLATE ILL 

A. Intertrigo. 

B. Seborrhcea capitis of infants. 

C. Cord, 24 hours old. 

D. Cord, 6 days old. 

Napkins. 

1. Detritus of uric acid infarction (stain on napkin during early days of life). 

2. Meconium. 

3. Color of faeces resulting from good human breast-milk. 
4 <( u << n a a a 

5. Crystals of uric acid and urate of ammonium (hedgehog crystals) taken from 10. 

6. Substitute feeding. Fat, 2 per cent. ; milk-sugar, 5 per cent. ; proteids, 1 per cent 
•7 u (i a g u (i g (( t( j a 

8. " " " 4 " " 7 " "1 " 

g_ a a ic 4 " "7 " '* 1 l ' 

10. Detritus of uric acid infarction in excess. 

11. Bile-stain on napkin. 

12. Color of faeces after bismuth 3 grains was given every two hours for six doses. 

13_ (< ft a a 4 (t u (i u 

14. " " " " was omitted for twenty-four hours. 

15. Color on napkin commonly seen, but in this case excessive in amount and patho- 

logical from uric acid. 

16. Color of " clay-colored" faeces. 

17. Color of the change in milk-fed (breast or otherwise) infant's faeces which may 

occur just before or just after they are passed (not necessarily pathological). 

18. Pathological color as seen in case described on page 809. 



84 



: e in 



w 




NORMAL DEVELOPMENT. 85 

in early life ; the solitary and agminate follicles are rich in lymphoid 
tissue. 

THYROID. — The thyroid body is relatively greater in the infant than 
in the adult. 

URINE. — The function of the kidney begins quite early in foetal life, 
and the bladder has been found to be full of urine at birth. The urine is 
small in amount at birth, and during the first twenty-four hours it is not 
uncommon to find little or none passed. The urine which is first passed 
is usually dark, cloudy, and acid ; later it becomes clear, pale straw-yellow, 
and usually of slightly acid reaction. Its specific gravity (1.010 at birth) 
falls in two or three days to 1.003, by about the fifteenth day is found to 
be 1.006, and rises from this time steadily till puberty. By the end of the 
first week and throughout childhood the amount of urine passed in 
twenty-four hours is relatively greater than in adult life. This in early 
infancy may be due to the preponderance of liquid food, but is in part 
the result of the infant's more active metabolism, for the urea is also 
found to be proportionately increased. According to Foster, the presence 
of uric and oxalic acid in unusual quantities is a frequent characteristic of 
the urine of children. It is also stated that the phosphates are deficient, 
being retained in the body for the purpose of building up the osseous 
system. The chlorides, sulphates, and urinary pigments are less abundant 
than in the adult. The proportion of salts increases as soon as a mixed 
diet is given and closely approaches to the normal proportion for 
adults. Indican is normally absent in breast-fed infants ; in others it is 
usually absent unless there is a disturbance of digestion. The uric acid 
infarction, which has been referred to, and evidences of which may 
last for two or three weeks, consists of urate of ammonium (hedgehog 
crystals), amorphous urates mixed with uric acid crystals, and some epi- 
thelial cells (Plate III., facing page 84). The variations in the amount 
of urine which has been computed to be passed during the early days of 
infancy and childhood are very great, as the amount in all probability 
depends very largely on the quantity of liquid ingested, and also upon 
the activity of the skin and bowels. It is well, however, to have some 
general idea of the normal total amount of the urine at different ages in 
order to understand better the diseased conditions of the kidney. 

The difficulties in accurately measuring the amount of urine excreted 
by very young infants are such that few positive statements can be made 
as to the quantity. It is sufficient to say that it is about ninety cubic 
centimetres (three ounces) a day for the first few days, and then rises in 
amount very rapidly. 

Rietz and Cruse state that during the first few days of life the urine 
contains more or less albumin, and that this disappears at about the 
seventh or eighth day. It also frequently happens that the first urine that 
is passed is cloudy. Sugar is occasionly found in the urine of healthy 
infants during the first two months. 



86 



PEDIATRICS. 



The following figures, compiled in part by Holt, are the averages 
obtained by combining the results of the investigations of Schabanawa, 
Cruse, Camera, Pollak, Martin-Ruge, Berti, Schiff, Herter, Vierordt, 
Renault, and others : 



Days 



Months 



Years 



Adult. 



Daily 

Quantity of 

Urine in 

Health. 



0-60 C.C 
10-90 



90-250 



150-400 



210-500 



1 

2 

3 

4 

5 

6 

7 

8 

9 
10 

1 

2 

3 

4 

5 

6 

7 

8 

250-600 
10 
11 
12 

1 

2 ) 

3 y 500-800 

4 

5 



y iooo-i50O " 



Specific 
Gravity. 



TABLE 22. 



Ratio of 

Uric Acid 

to 

Urea. 



:. c ::::l 1 



600-1200 " 



1.004-1.008 



1.004-1.010 



_ 1.006-1.012 



1.008-1.016 



1.012-1.020 



1 to 14 



1 to 60-80 



1 to 50-70 



1 to 45-60 



Daily 
Quantity of 
of Urea in 

Gm. 

0.076-0.114 . . . 



0.140-0.660 . . . 



0.90-1.40 
3.0 (?)'.'.'. 



13.09 to 14.01. 



16.05 to 21. 



Quantity of 

Urea per 

Kil. of Body 

Weight. 

0.0205 



No. of C.C. 
of Urine 
for each 

Kil.ofBody 
Weight. 



0.0919 , 
0.23 . . . 



0.5(?). 



I ?py. 



Girl, 
Boy, 



1.017 

0.961 

1.06 

0.811 

0.61 



| Boys 



Girls, 
Boy, 



53.03 
48.00 
78.00 
47.06 



0.88 

o.6oe 
:6.*55 ' 



75.64 
23.i2 
.28.66 



The urinary sediment of the young infant shows on microscopical 
examination mucus, many epithelial cells, crystals of uric acid, urates, 
and calcium oxalate ; also amorphous urates, occasionally a few hyaline 
casts, and rarely a granular cast. The urine of later infancy and child- 
hood has no microscopical peculiarities. 

INTESTINAL DISCHARGES.— The contents of the intestine con- 
tinue to be mixed with meconium for three or four days or a week, the 
longer time being when the infant is weak and does not nurse well. After 
this time the infantile discharges, which have a characteristic appearance 
as distinguished from those of the older child, appear. It is necessary to 
be familiar with their characteristics, as they are an important guide to the 
proper feeding of the infant and are an index showing whether the food 
is properly digested and assimilated. When the nutriment is milk, with 
the percentages of its different elements corresponding to what is normally 
found in good average human milk, the discharges are of a golden yellow 
color, smooth, unformed, of medium consistency, showing a large pro- 
portion of water, and sometimes changing on exposure to the air to a 



Fig. 29. 



Fig. 28. 





Infant at term, shelving large head, large ante- Iniant at 19 months, showing large head, small 

rior fontanelle, small thorax, cartilaginous ster- anterior fontanelle, ossification of sternum, tilted 

num, tilted pelvis, and bow-legs. pelvis, and straight legs. 

Warren Museum, Harvard University. 



NORMAL DEVELOPMENT. 87 

greenish yellow. They as a rule contain undecomposed bile-pigment and 
bile-salts, while the older child's and the adult's discharges do not contain 
the bile undecomposed. The amount of faecal discharge in the first day 
of life is about forty-five grammes (one and one-half ounces), and in- 
creases in the following days to fifty grammes (one and two-thirds ounces). 
It consists of mucous, fat, epithelial remains, and a slight amount of albu- 
minoid material. In early infancy there are from two to four discharges 
daily. As the child grows older there are two and finally one in the 
twenty-four hours. They do not lose their yellow color until amylaceous 
or albuminous food is given, when the different shades of brown begin to 
appear. They are not fully formed until something besides milk is swal- 
lowed. Starting at birth with the sterile meconium, infection by the mouth 
and rectum quickly occurs, and in a short time almost any form of bacteria 
may be found in the discharges, but chiefly such putrefying forms as pro- 
teus vulgaris (Jeffries). With the suckling of the infant and the substitu- 
tion of the refuse of the milk and the secretion of the digestive tract for 
the meconium, a sharp transition occurs. Instead of the generally dis- 
tributed forms, causing decomposition, only two kinds of bacilli are now 
regularly found, the bacillus lactis aerogenes and Brieger's bacillus, the 
first chiefly in the upper parts of the intestines, the second in the lower 
part. When the infant begins to take a mixed diet, quite a number of 
forms of bacilli appear, among them the streptococcus coli gracilis, the 
putrefying green fluorescing, a tetrad coccus, and several kinds of yeast. 
The color of the infantile intestinal discharges when the nutriment is milk 
alone, whether human or animal, seems to depend somewhat on the per- 
centage of fat, as is seen in Plate III., facing page 84, where the color 
resulting from the food containing different percentages of fat is repre- 
sented in Nos. 3, 4, 6, 7, 8, and 9. 

INFANTILE SKELETONS. — Fig. 28 represents the skeleton of an 
infant at term, and Fig. 29 that of an infant at nineteen months. These 
skeletons illustrate some of the differences which occur in the bones 
during their process of development. 

In the younger subject the head is large in proportion to the small 
thorax, and there is a lack of development of the face in comparison with 
the head, which is very evidently due to the rudimentary development of the 
jaws. The anterior fontanelle is widely open. On examining closely the 
sternum it will be noticed that it is not in one piece, as in the adult, but 
that the centres of ossification with the intervening cartilaginous connec- 
tions are well marked. The pelvis is tilted forward, as compared with 
the adult's, and is small and contracted. The legs are not straight, as in 
the older child, but show decided bowing of the tibia and fibula. This 
characteristic condition of the legs in intra-uterine life is present at birth 
and continues for some months, the bones usually becoming straight by 
the time that the period of walking has been reached. In the skeleton of 
the infant nineteen months old, the legs have developed naturally in their 



88 PEDIATRICS. 

growth and are straight. The pelvis still tilts somewhat, but is evidently 
less contracted, or rather has begun to enlarge. The thorax has broad- 
ened in comparison with the head, and the cartilaginous sternum has 
become to a large degree bone. The head is still large proportionately to 
the face, although the jaws have developed considerably beyond what is 
seen at birth. The anterior fontanelle is quite small in comparison with 
the fontanelle of the new-born infant. These are the chief characteristics 
of the infant's and child's skeleton. 

NORMALLY DEVELOPED INFANTS.— One of the greatest draw- 
backs to the proper appreciation of the kind of knowledge which is. 
needed to examine and treat children successfully and intelligently when 
they are sick, is the lack of precise facts concerning healthy children. 
It is therefore important to know at a glance whether it is normal for a 
child not to sit alone or not to stand alone, and to understand its childish 
actions, whether in creeping or in walking. 

The ages at which infants develop so as to gradually become chil- 
dren are important to determine, for it is just as wrong to task by prema- 
ture use the function of locomotion as that of digestion. A normal infant 
should hold up its head without support at the second or third month ; it 
should sit alone at from seven to nine months, creep at about ten months, 
stand at about twelve months, and walk at about fifteen months. 

TOPOGRAPHICAL ANATOMY OF THE EARLY PERIODS OF 
LIFE. — It is important, for purposes of diagnosis, to recognize the fact 
that the organs differ in the space which they occupy in the body accord- 
ing to the stage of development of the child. Well-marked periods are 
thus shown to exist by physical examination as well as by anatomical re- 
search, and the results of these different methods of investigation are 
found to correspond. I have always found that a careful consideration 
of the period of development is of the first importance when beginning to 
make a diagnosis of disease, especially of the heart and lungs. The large 
size of the liver in infants and the comparatively greater proportionate size 
of the heart to the lung in the middle years of childhood are striking in- 
stances of the truth of this statement, and should warn us that more than 
ordinary care should be employed in diagnosticating a pneumonia of the 
right lower lobe behind in infancy, or a dilated heart in childhood. Three 
periods of growth are of especial significance in this connection : 1. A 
period corresponding to the development of the organs in the first year, 
especially in the first half of the year. 2. A period occurring during the 
fourth, fifth, sixth, seventh, and perhaps eighth and ninth years. 3. A 
period embracing the later years of childhood. 

Figs. 30 and 31 represent the first period. This infant, seven months old and: 
normally developed, has, outlined in black, the principal points both in front and be- 
hind which will be useful to remember when making a physical examination at 
this age. 



NORMAL DEVELOPMENT. 



89 



In Fig. 30 the plain dark lines have followed the lower margin of the ribs and 
the outline of the ensiform cartilage and manubrium. To the left of the lower part 
of the left sternal line is a small curved line. This represents the superficial dulness 
of the heart. The relative or deep dulness is very slight. By very delicate percussion 



Fig. 30. 



Pig. 31. 





Normal infant seven months old- 



it may be shown to extend above to the second rib, to the left about 1 cm. (J inch) 
outside the mammillary line and to the right about 1 cm. (£ inch) beyond the right 
sternal border. The area of superficial dulness can almost be covered by the end of 
the finger used for percussion. It is bounded by the fourth rib or third interspace 
above, and is just within the mammillary line. There is very fair resonance under 
the whole length of the sternum. The interrupted lines represent the upper and 
lower borders of the liver. There is not much to say about the upper line, but the 
lower one is interesting and instructive as illustrating the large size of the liver in 
early infancy, and how little of the stomach, which is here represented by a dotted 
line between the edge of the liver and the left border of the ribs, is to be reached by 
percussion. The stomach is, of course, in this infant, empty. When full, it comes 
out much farther under the edge of the liver. The broad black line just above the 
level of the umbilicus marks the transverse colon, which in infancy has a relatively 
low position. The caecum, which is marked by a black circle, stands high in the 
abdomen, near the anterior superior spine of the ilium. The upper piece of the 
sternum is also outlined, as is the clavicle and first rib. Fig. 31 shows the same 



90 



PEDIATRICS. 



infant's back ; the lower borders of the thorax, the kidneys, and the lower borders 
of the lungs are outlined. The left kidney is decidedly higher than the right at this 
age. While the lower border of the lung on the left comes down as far as the tenth 
rib, the corresponding border of the right lung, owing to the large size of the liver, 
descends only as far as the ninth rib. 

Figs. 32 and 33 represent a child in the second period of its growth. 
In this middle period of childhood the heart has developed more rapidly 
proportionately than the lungs, and its area of superficial dulness takes 
up more space in the anterior portion of the thorax. 



Pig. 32. 



Fig. 




i #" 



Normal development at six years. 



He was six years old, properly developed for his age, and presented certain 
points of interest which differ from the infant and the adult, and which should be 
carefully taken into account when we are making a physical examination at this age. 
The manubrium, the clavicles, the first and second ribs, the ensiform cartilage, and the 
lower borders of the thorax are marked in black. The area of superficial cardiac dul- 
ness is far greater than in the infant, Figs. 30 and 31. The dulness should, so far as the 
sternum is concerned, be determined by light percussion directly over the sternum from 
above downward. In this way we can detect the change in the percussion note over 
the lower part of the sternum better than by percussing from the lung to the sternum, 



NORMAL DEVELOPMENT. 91 

since the former is so much more resonant that the sounds are more difficult to dis- 
tinguish and are often misleading. The upper resonant part of the sternum, on the 
other hand, presents an excellent opportunity for comparison, and brings out the 
delicate shades of sound which are needed in getting the relative dulness. This 
relative dulness, however, is usually pronounced under the lower part of the ster- 
num in this period of development, and it shades off into the absolute or superficial 
dulness of the precordia. Absolute dulness under the sternum, unless depending on 
pathological conditions, is rare even at this age, when it is also rare not to have this 
physiological relative dulness. In this period the superficial dulness of the heart 
extends higher in the left parasternal line than at any other time of life. The lower 
border of the third rib usually marks the upper border of the superficial dulness, which 
extends also to the left sternal line and keeps well within the mammillary line. The 
relative or deep dulness, on the other hand, reaches as high as the lower border of the 
second rib. It then passes to the right under the upper third of the sternum, descends 
obliquely to the fourth right costal cartilage, and then keeps slightly to the right of the 
right sternal line. To the left it extends well out to and perhaps a little over the 
mammillary line. This is a far different result of percussion from that which is found 
in the adult, and also in the infant represented in Fig. 30, in whom there is no dulness 
under the sternum and the superficial dulness rises only as high as the fourth costal 
cartilage in the left sternal line. The deep dulness also extends only as far as the 
mammillary line. The impulse of the heart is usually found a little higher in infants 
and in young children, irrespective of these periods, than in older children and in 
adults, and is usually in the fourth interspace. 

A much smaller space is occupied at this age by the liver than in infancy. The 
liver is indicated by the double line, which rises as high as the fifth rib in the mam- 
millary line, and to the attachment of the sixth or seventh right costal cartilage to the 
sternum. The dotted line of the stomach, on the other hand, occupies a much larger 
space than in the infant. The line of the transverse colon stands proportionately 
higher, the caecum rather lower. Fig. 33 shows the lower border of the right lung 
still to be a trifle higher than that of the left, and to come to about the upper border 
of the tenth rib, while on the left side it extends to the lower border of the same rib. 
At this age the liver has diminished in size relatively to such an extent that the differ- 
ence of the position of the lower borders of the lung is but slight. 

The kidneys are about on a level on both sides. The first and twelfth dorsal 
vertebras are also indicated as landmarks. This child is passing through transitional 
stages of physical development, and is gradually approaching the adult type of per- 
fected growth. 

Perfected growth, so far as the topography of the organs is concerned, 
is reached in the third period represented in the last years of childhood 
and at about the age of puberty. The organs of the child seem at this 
age, although they have not yet acquired their complete growth, to present 
for purposes of percussion the outlines which we are accustomed to see 
in the adult, with the exception possibly of the position of the caecum. 

Fig. 34 shows a normally developed boy, twelve years of age, and illustrates re- 
markably well the relative topographical correspondence of later childhood and adult 
life. 

As in the boy of six years, the manubrium, clavicle, first and second ribs, ensi- 
form cartilage, and the lower borders of the thorax are outlined in black. The 
curved line passing up the left sternal line to the fourth rib and keeping within the 
mammillary line marks the superficial dulness of the heart, and corresponds to the 



92 



PEDIATRICS. 



topography of the adult's heart. The relative or deep dulness is the same as in the 
adult. The upper line of the liver is about at the level of the fifth rib in the mammil- 
lary line, and does not extend beneath the lower border of the ribs, but is just below 
the tip of the ensiform cartilage. The dotted line represents the stomach. The spleen 
has its upper border at the ninth rib, and its lower portion comes down as far as the 



Pig. 34. 



Fig. 35. 





>, 



Normal development at twelve years. 

lower border of the eleventh rib. The caecum is marked in the upper part of the right 
groin. The transverse colon is about midway between the stomach and the umbilicus. 
Looking at this same boy from behind (Fig. 35), it will be seen that the kidneys and 
the lower borders of the lungs are in about the same relative position as occurs in the 
adult. I have also indicated the first and twelfth dorsal vertebras. 



These representatives of the normal development of important periods 
of life not only were carefully mapped out by myself by percussion and 
in accordance with the anatomical knowledge which we possess on this 
subject, but also were verified by Professor D wight, who examined each 
child carefully and satisfied himself that my marking was correct. 

NURSERY. — Before undertaking to treat the various diseases of early 
life, it is of great importance to acquire a practical knowledge of the care 



NORMAL DEVELOPMENT. 93 

of the infant and child in health. It is essentially in the nursery that we 
should study the healthy child, as the nursery is its home, where it feels 
most at ease and behaves in the most natural manner. The general 
hygiene of the child is represented in its nursery, and we should therefore 
by our knowledge and advice so direct these questions of nursery hygiene 
as to give this sensitive, easily impressionable young human being the best 
opportunity to develop into a healthy and vigorous adult. We cannot, of 
course, in every case procure for the child the surroundings which are 
best for it, but we can at least impress on the parent what these surround- 
ings should be, and how important they are for the general health of the 
child. The nursery should be high from the ground and out of reach of 
the dampness which arises towards the latter part of the day. 

Sun and Windows. — It should have a sunny exposure and large win- 
dows high enough from the floor to avoid having the younger children 
continually pressing their faces against the glass to look out, and thus 
frequently catching cold from the little currents of air which penetrate 
most window-casings. The mothers often overlook this simple manner 
of catching cold, and wonder how their children, who are so closely 
watched, could have contracted the catarrhal conditions which arise in this 
way. 

Papers and Carpets. — It is much better not to have a paper on the 
walls or a carpet on the floor. Young children are very susceptible to 
inhalation poisons, and to organisms of all kinds. Many a case of anaemia, 
nasopharyngeal catarrh, and stomatitis ulcerosa has apparently arisen 
from arsenic in the paper. Dust also, with its multitude of organisms, 
which with the most careful sweeping it is impossible to get rid of, is an- 
other source of irritation to the respiratory tract. Even small amounts of 
arsenic in the contents of the house appear to affect certain children, and 
the paper itself is a receptacle for micro-organisms which are difficult to 
eradicate. 

Picture-Mouldings. — It is advisable not to have any picture-mouldings 
on the walls, as they are a place for dirt to gather which it is impossible 
to remove properly. 

Floor. — There should be as few cracks as possible in the floor, and it 
should be smooth, so as to be easily cleansed. The floor, however, 
should not be highly polished, for children frequently fall while playing, 
and sometimes quite severe accidents occur in this way. 

Walls and Ceiling. — The floor, the walls, and the ceiling should be 
painted. Not only can they then be frequently washed and scrubbed, but 
when the child happens to have any of the contagious diseases, the whole 
room can so easily be disinfected that it saves much trouble and expense. 

Rugs. — A rug is desirable in the middle of the room. It should never 
be an antique ; in fact, it is better to have new,x simple carpet rugs. The 
rugs should not be too large nor too heavy to be frequently taken out into 
the open air and thoroughly beaten. 



94 



PEDIATRICS. 







Bed. — The child's bed should be iron, painted so that it can be care- 
fully cleansed by wiping, and its sides, as the child grows older, should al- 
ways be kept high enough, by some simple contrivance, to prevent the child 

from climbing over them. As 
FlG - 36 - few hangings and useless curtains, 

with which the mother is usually 
so desirous of draping the bed, 
should be used as possible. Fig. 
36 represents the bed used in 
the wards of the Infants' Hos- 
pital, and it is to be noticed |hat 
the bed is of such a height that 
the infant can be easily handled 
and examined when sick by the 
physician without his stooping 
much. 

Having the bed high from the 
floor serves another purpose, — 
namely, that the draughts from 
the windows and doors pass 
under the bed rather than on 
to it. 

Pillow and Mattress. — The 
pillow and mattress should be 
of felt, folded so as to be soft and 
comfortable, and pillow and mat- 
tress cases should be used. When this is done the felt can be unfolded 
and aired every day, and both the felt and the cases washed and boiled 
when necessary. The mattress should be protected by a rubber sheet. 
Especial precautions should be taken that the child does not kick off the 
clothes at night. It is well for the nurse's bed not to be close to that of 
the child. This entails a little extra trouble on the nurse's part, but her 
breath is not a healthy pabulum for the child's lungs, which require fresh, 
pure air of their own. 

Closets and Drawers. — The child should have its own closet and 
its own bureau-drawers. The nurse's belongings ought to be kept in a 
separate room. The closets and drawers should be cleansed at least once 
a week. 

Furniture. — There should be sufficient furniture in the room for com- 
fort, but stuffed furniture should be avoided. As little as possible that is 
complicated or cumbersome should be kept in the child's nursery. 

Curtains. — Only simple muslin curtains, which can be washed, should 
be used at the windows. 

Toys. — As a child puts everything that it gets hold of into its mouth, 
care should be taken not to allow it to have toys with colors that can be 




Infant's bed, Infants' Hospital. 



NORMAL DEVELOPMENT. 95 

soaked off by its saliva, which would perhaps poison it. Toys also which 
are made of woollen materials or of feathers should be avoided, as parti- 
cles easily come off them. 

Heating and Ventilation. — The heating and ventilation of the nursery 
are of great importance. The child requires pure, warm air. The tem- 
perature of the room can vary somewhat according to the climate, but, as 
a rule, the average should be from 18.8° to 21.1° C. (66° to 70° F.). 
The open wood-fire is best both for the character of the heat which it 
gives, and for its value as a means for promoting ventilation. 

A plain piece of wood the width of the window, about 10 cm. (4 
inches) high, and made to fit closely to the window-sill, is the best ven- 
tilator, but is rarely needed where a wood-fire is burning in the room. 
The upper sash can also be lowered for a few inches if more air is 
needed. 

Draughts.— We must take into consideration the currents of air in 
the nursery, so that the mother, understanding the atmospheric conditions 
which surround her child, can give the simple directions, which she has 
learned from us, to the nurse. This is by no means an unnecessary pre- 
caution, for one of the worst cases of rheumatism in the hip-joints which 
has come under my notice was that of a child two years old who was 
allowed to sit on the floor with its back to the open door, and directly 
in a line with the open fireplace. The direction of the currents of air 
between the doors, windows, and open fireplace is admirably and scien- 
tifically described by Mr. John Pickering Putnam in his valuable work 
entitled " The Open Fireplace," in which the direction of the cold-air cur- 
rents is shown to enter the windows, descend to within a few inches of 
the floor, and then to radiate towards the open fireplace and doors. If 
the child is much on the floor, a sheet can be placed over the cracks of the 
door ; and plain white sheets are always the best articles for screens or 
portieres. 

Where the current of air is too strong it can be tempered by pinning a 
towel across the opening between the upper and the lower sash. This 
should at once suggest to the mother that parts of the room, on account 
of these currents of air which from doors and windows pass over the 
floor to the fireplace, should be avoided not only for bathing but also for 
playing on the floor. 

A high fender covering the entire opening of the fireplace, and fastened 
so that the older child in playing cannot pull it down, is an important 
part of the nursery equipment. It answers two purposes, — one to pre- 
vent the sparks from flying out on the child, the other to prevent the child 
from falling into the fire. Serious accidents have happened from a lack 
of proper precaution regarding this apparently self-evident necessity. The 
hot air from the fire radiates in all directions into the room. 

Scales. — Properly adjusted scales are an important part of the nursery 
equipment. The scales which are usually provided are, as a rule, very 



96 PEDIATRICS. 

inadequate for the minute and daily weighing, the results of which are at 
times of such great assistance to the physician in the management of the 
infant's food. Never hang an infant in anything on a hook to weigh it. 
Such weights are usually, from the continual kicking of the infant, quite 
incorrect. Do not think that the kitchen grocery scale is good enough for 
the infant. We can afford to have incorrect and approximate grocery 
weights, but cannot afford to apply these methods to the growing infant, 
with its unstable equilibrium. The scales should be of a small but solid 
platform variety, which can be placed on a firm table by the tub where 
the infant is to be bathed, for use before the bath. 

The scales should weigh as low as four or five grammes (one drachm). 
A basket, with a small soft blanket lining it, is placed on the platform of 
the scale, and the naked infant is weighed in the basket. The scale is 
balanced, and the infant immediately taken out of the basket without 
stopping to read the weight, so as not to expose it too long while uncov- 
ered. When the infant has been dressed the scale can be read, and the 
balance-weight minus the weight of the basket and blanket (which can, 
of course, always be a constant quantity) gives us the exact weight. 
Weighing with the clothes on is a very unsatisfactory procedure. 

BATHING-. — The question of the bath is of a good deal of importance 
in the early months of life. Unless there is some definite contra-indica- 
fion, an infant should be bathed every morning. The contra-indications 
are if the skin or nails turn blue, or if the infant seems in any way to 
show symptoms of weakness or lowered vitality after bathing, such as are 
represented by cold extremities and nose, or an unusually quickened res- 
piration. In these cases sponging, merely sufficient for cleanliness, is to 
be substituted for the bath. The bathing should be done with celerity, 
the tub being placed on the side of the fireplace opposite from the win- 
dow, and fronting the latter, so as to avoid draughts and insure a good 
light. The nurse should sit with her face to the light and have the in- 
fant on her lap, wrapped up in a warm blanket, with its feet towards the 
fireplace, and its head in such a position as regards the window as to 
avoid having too much light in its eyes. There should be a rack for the 
towels, which should be kept warm in front of the fire while the infant 
is being bathed. The clothes should in like manner be neatly spread 
out on another rack, ready to be put on as soon as the infant has been 
dried. 

Temperature of Bath. — The water should vary in its temperature 
somewhat with the age of the infant, but should never be so cold as to 
cause blueness or cold extremities. We must also be careful not to have 
the water too hot, as this has sometimes proved to be injurious. Each 
infant, however, must have the temperature of its bath adapted to its own 
vitality. A convenient bath thermometer is one which is guarded from 
breaking by a wooden frame, which also allows it to float in the water, 
and the nurse is thus enabled to see at a glance that the bath-water is 



NORMAL DEVELOPMENT. 97 

remaining at the proper temperature. The following table may be taken 
as a guide : 

TABLE 23. 

Temperature of the Bath for Different Ages. 

Age. Centigrade. Fahrenheit. 

At birth 36.6° 98° 

During first three or four weeks 35° 95° 

One to six months 34° 93.2° 

From six to twelve months 32.2° 90° 

Twelve to twenty-four months 30° 86° 

Then gradually reduce in summer to 26.6° 80° 

In the third or fourth year, if possible, reduce to 23.8° 75° 



The nurse should first wash the face in clear water, keeping the body 
and limbs wrapped up in a warm blanket. The face is then wiped with a 
soft towel. She should gently cleanse the nose, the corners of the eyes, 
and the external ears. The nose is especially important, for the infant's 
vitality is easily affected by occluded nares. The nurse should then soap, 
wash off, and dry the scalp. The sponge and water in the other division 
of the bathing basin are then used for soaping the body and extremities. 
Especial care should be paid to the folds of the neck, the axillae, groins, 
genitals, and anus. The temperature of the water in the basin and bath 
should, be taken from time to time with the wooden bath thermometer 
until the washing is over. The proper warmth of the water is to be 
kept by adding when necessary a little hot or cold water from cans 
within easy reach. 

Tub. — The tub, which is preferably made of rubber hung on a simple 
wooden frame and sufficiently high to prevent needless stooping on the 
part of the nurse, is placed on the nurse's left, at a convenient distance 
from her chair. 

Basin. — In front of the nurse is the double washing basin, which is 
merely a china basin divided into two compartments, and fitted to a 
wicker stand, also sufficiently high to prevent the nurse from stooping as 
she uses it. To the right of the nurse is the table, with the scales on one 
end and the toilet basket on the end towards her. 

Soap. — The soap should be white castile, or any kind which is free 
from irritating elements. 

Sponges. — There should be two sponges : one goes in one side of the 
washing basin, and is for the head and face ; the other is to be used in the 
opposite side of the basin, and is for the body and extremities. The body 
and limbs having been thoroughly and quickly soaped, the nurse should 
gently lower the infant with its face up into the clear water in the bath, 
being careful not to frighten it or to drop it. This is not an unnecessary 
warning. I have known infants, even in the hands of ordinarily careful 
mothers, to be dropped from the bath or scales, with a resulting perma- 
nent injury of the spine or hip. After allowing the infant to kick and 

7 



98 PEDIATRICS. 

splash for a few seconds, it is taken back into the nurse's lap and care- 
fully dried with a warm, soft towel. Never soap and wash the infant in 
the bath, but always on the lap. 

Powder. — When the skin is perfectly soft, clear, and in a normal con- 
dition, no powder is needed. Where there is any slight irritation, which, 
at times, is liable to occur when the skin has not been kept sufficiently dry, 
especially if there is a decided redness in the folds of the skin, as of the 
neck, axilla?, or groins, the following powder can be applied : 

Prescription 1. 
Metric. Apothecary. 

Gramma. 

R Pulv. zinci oxidi 7 

Pulv. amyli trit 60 



5 R Pulv. zinci oxidi gii j 

Pulv. amyli trit ^ ii. 



M. M. 

No perfume of any kind should be added to the powder. The infant 
should be sweet and pure in itself, without accessory odors. 

CLOTHING. — It is very important that those who care for the infant 
should not only clothe it properly but should understand why one method 
of clothing is better than another. The surface of the infant's body is 
greater in proportion to its entire weight than is the case in the older and 
hence larger human being. Greater surface means that there is a greater 
opportunity for radiation, and hence that the smaller subject will cool off 
more quickly, other conditions being equal, than the larger one. We 
therefore see at once that much care should be given to the question of 
warmth in the infant. Any exposure of the body or limbs in either in- 
fants or children is unwise. A very important factor in the problem of 
growth in the infant is perfect freedom of motion for its legs and arms and 
for the respiratory and abdominal muscles. It should also be thoroughly 
understood that pressure on any portion of the body or limbs must pro- 
duce evil results, by displacing organs which should be allowed to have 
entire freedom of position in their respective cavities. 

Too litttle warmth will do harm, by preventing the proper metabolism 
of the tissues and thus reducing the animal heat. Too great warmth, on 
the other hand, by causing inequalities in the circulation, will in like man- 
ner be detrimental to the child's growth and vigor. Clothes which bind 
any part of the infant tightly cannot but press out of their natural position 
whatever happens to be beneath the point of pressure, whether it be the 
liver, the intestines, or the toes. The clothes, then, must evidently be 
warm and loose, and we must bear in mind that loose clothes are warmer 
than tight ones, from the very fact that they do not interfere with t the 
natural activity of the circulation, and that they give freer play to all the 
muscles which produce the normal warmth arising from exercise. We 
must remember that the only way in which the infant can obtain the 
exercise so much needed for proper growth, and which is so easily ob- 
tained by the older child in running about, is by continually moving its 



NORMAL DEVELOPMENT. 99 

legs and arms and thus accelerating the muscular action of its thorax and 
abdomen. 

An important item in the proper management of the infant in its nur- 
sery is that it should be irritated as little as possible by unnecessary delay 
in dressing it after its bath. Useless stitches, buttons, and articles of 
clothing should be dispensed with, and a method adopted which, while 
combining the necessities of dress, will allow the dressing to be finished 
before it has time to annoy the infant. 

Abdominal Band. — There is no necessity for using beyond the first two 
or three weeks the usual flannel band supposed to be so indispensable 
by the average nurse. Hernias, whether umbilical or inguinal, cannot be 
obviated, and in fact may be produced, by undue abdominal pressure. 

The abdominal band shown in Fig. 37 A, made of light, soft flannel, 
can be smoothly applied over the dressing of the cord and kept in place 
with moderate pressure by means of safety-pins. 

The band can soon be replaced by a somewhat elastic knitted garment 
(Fig. 37 E, a), half band and half shirt, with shoulder-straps of the same 
material to hold it in place, and a tab in front to fasten it with a safety-pin 
to the napkin (Fig. 37 E, b). 

This shirt can be made of soft wool or silk, or, as I have recently 
found, can be knitted in any form or size from half cotton and half silk. 

This knit material can also be used for the undershirts (Fig. 37 B and 
Fig. 38 F, pages 100 and 103). Garments made in this way are the best 
that I have ever seen. They are warm, soft, and delicate, have no seams, 
can be washed without shrinking, and retain their elasticity much better 
than those made from other materials. 

Napkins. — The napkin (Fig. 37 E, b, page 100) is folded and fastened 
with safety-pins as is customary for keeping it in place. The usual nap- 
kin is very cumbersome and heavy, besides being expensive. It can be 
replaced by rolls of soft absorbent gauze, which absorb the urine from the 
skin, an important quality in cases where the skin is easily irritated. These 
napkins can simply be cut from the roll, which is kept in the nursery, and, 
when removed from the infant after a movement of the bowels, can be 
burned, thus avoiding the trials resulting from the objections of the nurse 
or the laundress to washing the napkins. If, however, the mother prefers 
the regular old-fashioned napkin, small squares of this gauze can be 
placed in the middle of the napkin, and this will in great measure obviate 
the more disagreeable part of the napkin- washing, as the square of gauze 
will hold most of the movement and can at once be burned. 

The infant while in long clothes need not have any further covering 
for its legs, and need have nothing on its feet. There is no particular 
objection to little knit socks if the mother wishes to use them. 

After the nurse has put on the band and the napkin there are left 
three garments which are usually the clothes needed to complete the 
infant's outfit of long clothes. 



L.oi 



100 



PEDIATRICS. 



Fig. 37. 
{Long Clothes.) 

A 



«i 






Flannel band for early weeks. 




A., knit band ; B, napkin ; C, stocking. 



NORMAL DEVELOPMENT. 101 

These garments are the shirt (Fig. 37 B, page 100), the petticoat (Fig. 
37 C), and the dress (Fig. 37 D). 

Shirt (Fig. 37 B). — The shirt is a garment with long sleeves and high 
neck, cut almost as long as the outside white slip or dress. Unless it is 
knitted it is well to have it made of some soft, fine, all-wool material, 
with the seams finished on the outside to prevent irritation of the skin. 
It is made to button in the back. A fresh garment of this kind is also suf- 
ficient for the infant's dress at night, except during the early weeks of life. 

Petticoat (Fig. 37 C). — A flannel shirt cut all in one piece, as the 
shirt is, made of fine flannel, with no sleeves and Avith low neck, repre- 
sents the petticoat. It should be made large enough to go over the shirt, 
should be of the same length as the dress, and should also be made to 
button in the back. The taste of the mother can be gratified by any 
reasonable degree of embroidery which she may wish to put on this 
second garment, but the shirt should be perfectly plain. 

Dress (Fig. 37 D). — The outer garment should be made of some soft 
white material, such as nainsook, should be large enough to go over the 
shirt and petticoat, should not be starched, and is usually about one yard 
long from the neck to the bottom of the skirt. It should have high neck 
and long sleeves, and should button behind. 

The advantage of this costume is that it is loose but warm, and that 
the three pieces which constitute it can be put on together, the infant 
having to be turned over only once before the clothes are buttoned. The 
other methods of clothing usually necessitate turning the baby over sev- 
eral times in the process of dressing. 

Before the infant has had its bath, these three articles of dress are to 
be arranged one inside the other, ready to be slipped on all three at once. 
This can be done with great celerity, and the dressing process can thus be 
gone through without the usual accompaniment of irritated cries which 
are so frequently heard in the nursery, and which are to be deprecated. 

When the infant is old enough to have its long clothes changed to short 
ones, which is at about the time when it learns to creep, the under-gar- 
ment can be replaced by a knitted or fine all-wool undershirt with high 
neck and long sleeves (Fig. 38 F, page 103) made short, with an additional 
white petticoat in winter if desired. The infant should now also have its 
feet and legs covered with long white wool stockings, which are kept in 
position by being pinned to the napkin (Fig. 37 E, b, page 100). When the 
child begins to walk, soft kid shoes should be used with the soles adapted 
to the natural curves of its feet, as explained on pages 104 and 105. 

Stockings. — A word in regard to the stockings is especially needed in 
reference to the older child in its third, fourth, and fifth years. It is a 
mistake to think that if we keep the feet and abdomen warm the legs can 
be left uncovered with impunity. Short stockings and bare legs, in my 
opinion, should be abolished, as a prolific source of catarrhal conditions. 
The argument is a poor one that certain children have been known to 



102 PEDIATRICS. 

grow up well and strong with, uncovered legs, or even that our ancestors 
were in the habit of depriving their children of suitable coverings for their 
necks and arms as well as legs, while they themselves were warmly 
clothed from head to foot. Our ancestors did and said many things which, 
to us, convict them of great ignorance. The stockings should be white. 
This is to insure freedom from poisonous dyes, which at times seriously 
affect the delicate skin of the young child. Colored stockings are a source 
of great gratification to lazy nurses and to those who wish to lessen the 
size of their laundry. 

There are three garments which are usually put over the shirt and are 
considered to complete the short clothes. These are the flannel petticoat, 
the white petticoat, and the dress, and they are to be made large enough 
to fit one over the other and thus to be put on all at once. 

Flannel Petticoat (Fig. 38 G, page 103). — The inner garment next to 
the shirt has a flannel skirt, a cotton waist, low neck, no sleeves, and is 
fastened with buttons in the back. 

White Petticoat (Fig. 38 H, page 103). — Next to the flannel petticoat 
comes a garment with a skirt of some soft white material, with a cotton 
waist, low neck, no sleeves, and also buttoned in the back. 

Dress (Fig. 38 I, page 103). — Finally, over all the other garments 
comes the dress, which is made with high neck and long sleeves, and is 
buttoned behind. 

Night-Dress (Fig. 38 J, page 104). — A regular night-dress can now be 
used, made of soft flannel, with high neck and long sleeves, and buttoned 
behind. An extra garment can in cold weather be worn under the night- 
dress if deemed advisable for the especial child. 

FEET. — In young children, although the foot may be well formed, it 
is very weak, so that the arch is easily broken down. The pad of fat, to 
which reference has been made under development, is a physiological 
protection against such breaking down. Children should not be allowed 
to walk until some time after they are ready to do so, always allowing, 
of course, that if they insist on walking they can seldom be restrained 
from doing so. As they get older, long walks with their parents should 
be forbidden, for it is through these long walks that the evils which have 
been explained are brought about. The child will get exercise enough 
at its play, and in doing so will not overtax the arch of the foot, or use 
its feet beyond the degree which nature intended. Children should not 
be told to turn the toes out too much, as this puts the arch in a position 
where the muscles give it least support. The average dancing-school 
master is a fair example of what, over-zealous ignorance combined with 
the respected traditions of the past can do to children's feet. 

SHOES. — Children's shoes should be rights and lefts, like those of 
adults, as the present style of straight shoes gives no support to the arch 
during a very important period of its growth ; this, moreover, also tends 
to push the great toe towards the median line of the foot, so as to cause 



NORMAL DEVELOPMENT. 



103 



Fig. 38. 
(Short Clothes.) 

F 




Dress. 



104 




Night-dress. 



enfeebling of the muscles which have so much to do with the proper 
elasticity of the feet. 

We should, therefore, have shoes properly adapted to the child's foot, 
— shoes that will at once be comfortable and leave the feet free .to develop 
and fulfil all their functions. The children's shoes as we find them in the 
stores have the two sides of each shoe symmetrical and equidistant from 
the middle line ; the right and left are told only from the arrangement of 
the buttons, and are frequently worn interchangeably. Now, the foot has 
no such median line on each side of which the parts are equally disposed ; 
and its two edges are very different, as a glance at the soles of a one-and- 
a-half-year-old child's feet shows (Fig. 39). 

It is well to note especially that the phalanges of the great toe do not 
naturally point towards the outer border of the foot : such a position, 
common as it is in the adult, must be considered as an acquired deformity 
which started, in all probability, with the first pair of leather boots. 

That this matter of forcing the first toe out of its normal position may 
bring with it very serious consequences is easily shown : as it inclines 
against the terminal phalanx of the second toe, it often crowds it back- 
ward, and finally makes it the distressing "hammer toe," which may even 
require a surgical operation for its relief. On the inside of the foot, as 
soon as the axis of the first toe is bent, we begin to find a bulging out of 



NORMAL DEVELOPMENT. 



105 



the metatarsophalangeal joint, which in later years, fostered by pair after 
pair of tight and ill-fitting boots, is capable of giving the most exquisite 
pain. Still more subtle in its working than this is the trouble that often 
comes from disabling the great toe from performing its full function. The 
elasticity of one's step depends largely upon one's power to press down 



Fig. 39. 
(Natural size, 1£ years. 




Unsuitable shape for sole of child's shoe. 



Suitable shape for sole of child's shoe. 



firmly with the great toe and then raise the weight of the body over it as a 
support ; when this is lost by crippling the toe with ill-shaped boots, the 
muscles not only of the first digit but of many adjacent groups begin to 
atrophy. This soon leaves the internal arch of the foot without sufficient 
support, and the long series of woes incident to " flat-foot" is started upon. 
Therefore, for one and all of these reasons, let us demand that children's 
feet shall have at least the chance to develop properly in well-fitting 
anatomical shoes. 

SLEEP. — Infants and young children vary much as to the amount of 



106 PEDIATRICS. 

sleep which they need and take during the day. At first they sleep 
almost continuously, especially if they happen to be somewhat premature. 
In a few weeks, however, they begin to have regular periods of rest, con- 
sisting of several hours' sleep, at first twice in the day, and later once. 
The more sleep they can be induced to take in the twenty-four hours, the 
better. As they grow older the amount of sleep which they take grows 
less, but in the first four or five years of life it is well to try to induce the 
child to rest quietly on its bed for at least an hour during the day. The 
number of hours that an infant or child sleeps varies so with the indi- 
vidual that precise rules cannot practically be given ; one simple rule holds 
true, — allow each child to sleep as long as it naturally can. 

WHEN TO GO OUT OF THE HOUSE.— If the infant happens to 
be born in the winter months and the weather is at all severe, it is better 
to keep it in a well-ventilated nursery than to run the risk of its vitality 
being lowered by exposure to cold. I believe that infants in our northern 
climate are exposed to cold far more than they ought to be, and that they 
need fresh, warm, dry air, rather than the cold and often damp air of our 
winter months. When they are born in a milder climate, or at a warmer 
season of the year, they can after the first few weeks be taken out in their 
carriages often twice a day. When the infant is five or six months old I 
am in the habit of giving the following directions to the mother as to when 
she shall send it out. I explain to her that it makes as much difference 
whether the air is damp or dry, and what the rate of the wind may happen 
to be, as does the number of degrees indicated on the thermometer. If 
the sun is shining, the air dry, and there is no wind, the infant can with- 
out harm go out for an hour in the middle of the day even at a tempera- 
ture of —6.6° to —3.8° C. (20° to 25° F.j. Where, on the contrary, the 
air is damp, or the rate of the wind is great, it is better for the infant to 
remain in its nursery, and, at any rate, not to go out, if the temperature 
is below 0° C. (32° F.). The practice of allowing the infant to sleep in 
the open air in its carriage in every kind of weather is, I believe, a bad 
one ; but on the days when it is proper for it to go out, such as I have 
already described, it can without harm sleep in the open air. The nurse 
should be directed to protect the infant's eyes from the direct rays of the 
sun, and not to allow a strong wind to blow in its face. 

Where the weather has been too severe or damp for the infant to go 
out in its carriage for some time, it is advisable to have it dressed warmly 
and wheeled up and down in its nursery with the window open for fifteen 
or twenty minutes. To avoid too much draught, blankets can be placed 
over the cracks of the doors and the open fireplace while the infant is 
breathing the fresh air. The room being far above the ground, the damp- 
ness is avoided, and even a considerable velocity of the wind outside the 
house will in this way be unable to affect the air of the room, and will 
not make too strong a draught. Where it is possible, as is the case in 
certain families who can afford such a luxury for their child, a solarium at 



NORMAL DEVELOPMENT. 107 

the top of the house, especially in cities, is desirable and practical. Not 
only should an injudicious administration of cold air be avoided, but 
extreme care also should be taken in hot weather that the child is not 
exposed to too great direct heat from the sun, and it should never be kept 
in a hot atmosphere where currents of fresh air cannot have access. 

NURSERY-MAIDS. — The idea that the child should be taken care 
of by an old, experienced nurse is a vicious one. The experience of 
nurses, as a rule, is that of ignorance rather than of intelligence. Every 
mother, as she is presumably more intelligent than the nurse whom she 
employs, and is surely more interested in the welfare of her child, should 
personally supervise and unhesitatingly investigate all that the nurse does 
to the child. The nurse's ideas as to what is needed for the child's 
hygienic surroundings, food, and clothing can well be dispensed with. 
The mother, learning from the physician what is best for her child, should 
give her directions to the nurse and see that these directions are strictly 
carried out. A nurse between the ages of twenty and thirty-five is prefer- 
able to one who is younger or older. She should be neat, healthy, strong, 
cheerful, gentle, and patient. She should be willing to refer small details 
of the nursery routine to the mother, as well as those which appear of 
greater importance. The chief attributes of a good child's nurse, in my 
opinion, are a desire to obey implicitly the orders which she receives 
from her mistress, and a temperament in harmony with the sensitive 
nervous organization of her charge. In certain cities, such as New York, 
Philadelphia, Buffalo, and Boston, schools have been established for 
nursery-maids. An admirable school of this kind has been carried on for 
some years at the Infants' Hospital in Boston, where the nurses are 
trained to be servants as well as nurses, the course lasting for one year. 
When intelligent girls trained in this way can be obtained, the preferable 
age is between twenty and thirty-five years. 

MOUTH. — A protest should be made against the way in which the 
nurse, and in fact almost every one who comes near the infant, put their 
fingers into its mouth on all occasions. It would seem as though the in- 
fant's mouth was considered by those avIio ought to know better as some- 
thing which was especially made to be felt. Infants are much more 
likely to have various diseases in their mouths than are adults, and prob- 
ably one reason for this is that dirt of all kinds is constantly being intro- 
duced into them. The fingers should always be thoroughly washed 
before entering the infant's mouth, and yet unwashed fingers are continu- 
ally feeling the baby's gums to ascertain if a tooth can be found. 

The nurse should be instructed that she is never to kiss the infant on 
its mouth, or allow any one else to. The germs of disease can well be 
transmitted in this way. It is partly through ignorance of doing harm, 
and partly through timidity on the part of the mother in prohibiting it, 
that a stop is not at once put to this bad habit of nurses and friends, and 
it is the physician's duty to warn mothers on this apparently trivial but 



108 PEDIATRICS. 

really important question, and to tell them how certain infectious diseases, 
especially tuberculosis, can be transmitted in this way. 

SCHOOL. — Much ignorance of the child's nervous organization is 
shown by those who should best know how to care for it, at a period of 
life when its hygienic surroundings, both mental and physical, are ex- 
tremely important. No one system is good for all children. I am sure 
that I have seen the kindergarten system do harm to a number of children, 
although it seems to suit others. Each child should be gauged for itself, 
and not be forced into any general system, even if that system has proved to 
be good for the many. No time is lost, in my opinion, in sending children 
to school at a somewhat later age than is usually supposed to be neces- 
sary. I am continually having to take little children out of school who 
are fretful and have loss of appetite. Neither parents nor teacher seem 
to appreciate that the little, actively growing brain is overtaxed by too 
great stimulation and is protesting against such treatment by these general 
symptoms. Many a child is being dosed with tonics who merely needs 
rest from school. The parents should keep the most rigid supervision 
over their children while at school, and notice from their behavior 
whether they are mentally tired. This supervision should not be left to 
the teachers alone, however interested they may be in their little pupils. 
It seems hardly necessary to state that the school-room should be well 
ventilated, and that at stated intervals during the school hours the win- 
dows should be thrown open and the atmosphere of the room completely 
changed. This should not, however, be done with the children in the 
room. Attention should be paid not only to what the children eat at 
lunch, but to how and where the lunch is eaten. A child really needs 
nothing but dry bread and milk or water between its meals, so far as its 
nutrition and digestion are concerned. 

DEFECTS OF POSTURE. — We can best appreciate the importance 
of following nature as closely as possible in its methods of developing 
young human beings so as to perfect their various functions to the fullest 
extent by examining carefully a group of malformed children. 

Back. — The extreme flexibility and slow development of the spine 
clearly point out to us that nature intends to leave its function in abeyance 
and bring it into use slowly. If the young infant is allowed to sit or stand 
at too early an age, the superincumbent weight of the large head tends at 
once to exaggerate the physiological curves of the spine to a point where 
they may become pathological. 

During the first year of life the strength of the spinal column is slowly 
increasing. Not before the seventh or eighth month has it acquired suf- 
ficient rigidity to warrant the child's being allowed to sit up. Artificial 
methods, therefore, of making the young infant assume a sitting posture 
at a period of development when the spine should be comparatively 
straight should be deprecated. I have met with numerous instances 
where both parents and nurses were anxious to have the infants, at a very 



NORMAL DEVELOPMENT. 109 

early age, sit for quite a long time strapped in small chairs. In like man- 
ner the same infants were encouraged to stand and walk long before the 
apparatus for locomotion was ready for use. One may ask, how many of 
these individuals developed a spinal curvature in later childhood ? Possi- 
bly the risk in a perfectly healthy child may be small. One often, how- 
ever, in early infancy, cannot determine which individual may become 
rhachitic, and where rhachitis is present the tendency to abnormal curva- 
ture is well known. 

We should, then, in our advice as to the proper physical management 
of the early years of life, be guided by our knowledge of the normal 
average development. Free play for the infant's legs, when lying on its 
back in bed, should be a point to be noticed and considered, since we know 
that pressing down the legs causes strain and curvature in the lower spine. 
Knowing the great lateral flexibility of the infant's spine, Ave should advise 
the nurse not to hold the infant continually on one side. Symmetry of 
development and free opportunity for natural movement should be our 
aim in the management of the infant from the very earliest period of its 
existence. Our knowledge of the great flexibility of the growing spine 
provides us at once with a most valuable means for treating lateral curva- 
ture in childhood, and we are continually seeing the benefit of encour- 
aging the promotion of elasticity by moderate pressure and bending. A 
case which was under my observation at the Infants' Hospital beautifully 
illustrates the truth of what has just been said. 

A feeble, rhachitic child, nineteen months old, was presented for treatment with 
a marked lateral curvature in the dorsal region, the convexity being towards the right, 
combined with decided rotation, following the type of the worst adult cases. 

The condition seemed to be purely the result of habit, the patient having been 
made, when very young, to sit up beyond the limit of endurance of the still undevel- 
oped bones and ligaments. The treatment was based entirely on the elasticity of the 
spine, and consisted simply of manipulation and recumbency, resulting in a very 
great degree of improvement both as to the curvature and the twisting. 

The improper treatment of the young subject's spine, as in infants, for 
instance, where they are carried altogether on one side, is well recognized 
as an important factor in the etiology of rotary lateral curvature. 

Remembering what has been said regarding the ossification of the dif- 
ferent parts of the spinal column, it will be understood that so long as an 
infant can be made happy in the prone position, whether in its nursery 
or in its carriage, it will be better for it to be kept in this position, always 
protecting the eyes when out in the open air from the strong light, and 
the face from the wind. During the first year w T hen it begins to sit up in 
its carriage its back should be carefully supported by a pillow. 

Fig. 40 represents the harm which can be done by encouraging children to sit up 
before their spinal columns are sufficiently strong. The infant, six months old, had 
been made to sit in a chair for hours at a time, strapped in a position which allowed 
it to use its arms, but such as to render it impossible to fall back and rest itself. 



no 



PEDIATRICS. 



The exaggerated curve of its back corresponds to that which would be seen normally 
at birth. Such a curve is shown in Fig. 3 (1), page 23. If this infant had not been 

Pig. 40. 




Posterior spinal curvature from sitting too soon. 



made to sit until it had developed sufficiently to acquire the pysiological curve (2), it 
would not at this age show any spinal curvature. It had, however, through improper 
treatment reacquired the posterior curvature (1) of the early hours of life. 

As the child grows older, weak undeveloped muscles have a tendency 
to allow lateral and posterior curvatures to be produced. Habit, of course,. 
has much to do with these faulty positions of later childhood. 

Figs. 41 and 42 represent a girl aged four and one-half years, with a lateral curva- 
ture, not from disease of the spine, but one which is usually explained as a result of 
superincumbent weight coming upon muscles which are unable to support it properly. 

On looking at her from behind, the curve which the line of the spinal column 
takes to the right in the dorsal region is quite distinct. On looking at this same child 
in front, the right shoulder is seen to be higher than the left, and the whole thorax is 
in a distorted position. These deformities are always more readily recognized by 
looking at the child in front and preferably across the room, as the outline of the chest 
and hips is much more clearly defined on the anterior aspect of the body than on the 
posterior. Posteriorly, in cases even of the slightest lateral curvature, one notices the 
difference in the level of the angles of the scapulae. This child stooped, and had 
what is commonly called round shoulders. 

In any case of round shoulders lateral curvature should be thought of 
and carefully eliminated. 

Faulty attitudes in sitting and standing play a great role in producing 
these curvatures. We must, however, acknowledge that such spinal curva- 



NORMAL DEVELOPMENT. Ill 

tures have been differently explained on the ground that they are the 
result of a lack of development of all the tissues upon one side of the 
spine. Other explanations have also been given ; but in certain individual 
cases it is impossible to formulate any reasonable cause for the curvature. 

Fig. 41. Fig. 42. 





Lateral curvature of the spine. Child •!% years old. 



Legs. — At birth the infant's legs are curved rather than straight, as is 
seen in Figs. 28 and 29, facing page 86. The natural tendency of the 
growth of the legs is to become straight, but if the child is encouraged to 
stand and walk too soon, especially if the bones have not been properly 
nourished, the weight of the head and trunk becomes too great to be 
supported by the legs, which curve outward in the form of an ellipse, a. 
condition which is called "bow-legs." The deformity of "knock-knee," 
in which the leg at the knee bends in rather than bows out, may occur 
from simple weakness, but is rare except in rhachitis, under which it wilL 
be more fully described. 



DIVISION II. 

FEEDING. 

GENERAL PRINCIPLES. 

Just as the highest aim of medical art should be directed to the prov- 
ince of preventive medicine, so the highest and most practical branch of 
preventive medicine should consist of the study of the best means for 
starting young human beings in life. They should be preserved from the 
perils which surround the early hours of their existence, and be given 
strength and vigor to resist the attacks which must inevitably be made on 
their vitality, and which are greater and more dangerous in inverse pro- 
portion to their age. With these objects in view, the preventive medicine 
of early life becomes pre-eminently the intelligent management of the 
nutriment which enables young human beings to breathe and grow and 
live. In fact, it is a proper or an improper nutriment which makes or 
mars the perfection of the coming generations. The feeding of infants is, 
then, the subject of all others which should interest and incite to research 
all who are working in the domain of pediatrics. The subject is a great 
one, and is worthy of the most careful study. The responsibility of dis- 
cussing so serious a question is a grave one. It should be taken up 
carefully. It should be dealt with broadly. We must acknowledge that 
in the status of feeding, as it has existed up to the last few years, the 
average human breast-fed infant was more likely to live, other conditions 
being the same, than the infant which was fed by any other method. But 
we must remember that the latest investigations of this subject show very 
clearly that it is not human milk as a whole which is pre-eminently good, 
but that it is a varied combination of the different elements of the milk 
which makes it the best food during the first year of life. It is our prov- 
ince to study and make use of these elements of the food, which were 
once somewhat mysterious, but which are now rapidly becoming known 
through the work of patient and careful investigators. 

In reviewing the immense amount of literature which has accumulated 
on the subject of feeding, Ave find that the superiority of human milk to 
all other kinds of infant food in the early months of life is acknowledged 
so generally that it has become an axiom. On the other hand, the 

112 



FEEDING. 113 

opinions expressed regarding artificial feeding in the past are so diverse 
and so opposed to one another that it is evident that much which has in 
former years been taught must be unlearned, or rather admitted to be 
untrue, before we can expect to make any decided progress in this most 
difficult subject. 

In our endeavor to copy nature we may hope that, as our knowledge 
increases, more and more light will be thrown upon those points which 
are now obscured by ignorance. It is, indeed, of the first importance 
that we should recognize our ignorance, and, watching every advance 
which science is making in this subject, be ready to sweep aside precon- 
ceived ideas which do not rest upon established facts, and thus by wise 
iconoclasm build our knowledge on a surer basis. 

The great number of artificial foods used by physicians according to 
the fashion of the day only proved that artificial feeding had never arrived 
at that state of perfection where it could compete with human breast 
feeding. The difficulty in approaching the study of the subject has been 
that physicians as a class have regarded it too purely from a clinical 
stand-point. We know, for instance, how easily we may be misled by 
the apparently good effects of a medicament when perhaps on further in- 
vestigation, or in the light of some new discovery, we learn that the im- 
provement in the case was due not to the drug, but rather to circumstances 
entirely apart from it. The same rule applies equally well to the case of 
many foods and methods of feeding. To state concisely what I have 
already referred to, we should, in studying the form of nutriment which 
shall be suitable for an especial period of life, manifestly be guided by 
what nature has taught us throughout many ages. The researches of 
science at present, especially in the subject of infant feeding, are wisely 
directed towards learning to read the truths which nature presents to us. 
Great progress has been made in reading these truths. What we are also 
endeavoring to do is to copy them, and in regard to human milk a great 
advance has been made in our knowledge as to what we are to copy 
from it. 

The feeding problem is one which is surrounded with many difficul- 
ties on account of the great diversity of individual circumstances and idio- 
syncrasies. Certain infants thrive on peculiar mixtures which are not 
adapted to infants as a class. Many will not thrive on that food which 
nature has provided for them, and the well-being of an infant will depend 
much upon the circumstances by which it is surrounded, such as affluence 
or poverty, country or city life. The constituents of the nutriment which 
nature has provided for the offspring of all mammals in the early period 
of their existence is essentially animal and never vegetable. Human 
beings in the first twelve months of life are carnivora. It is therefore 
evident that an animal food, entirely and freshly derived from animal 
and not vegetable sources, has been proved to be the nutriment on which 
the greatest number of human beings live and the least number die. 



114 PEDIATRICS. 

MAMMARY GLAND. — In regard to the early months of life, a 
knowledge of the changes which take place in the mammary gland from 
many causes is of vital importance and must be kept in view. The 
methods of modifying the milk in the mammary gland, however limited 
in their scope, should be carefully investigated and adapted to the indi- 
vidual infant according to its age and size and general physical condition. 
The mammary gland, in its perfect state, uninfluenced by disease or ner- 
vous disturbance, or by the improper living of the mother, is a beautifully 
adapted piece of mechanism constructed for the elaboration and secretion 
of an animal food. When in equilibrium it represents the highest type 
of a living machine adapted for a special purpose, — mechanically, physio- 
logically, and economically. When from any cause this sensitive machinery 
is thrown out of equilibrium, its product is at once changed, sometimes 
slightly, but again to such an extent that the most disastrous consequences 
may follow when it is taken by the young consumer. The breasts of 
all mammals are elaborators and producers. They are not storehouses 
for preserving sustenance until it is needed. They are delicately con- 
structed mills, turning out, when demand is made for it, a product which 
has been directly formed within their walls from material which has been 
brought through their portals from various parts of the economy. The 
breast is a compound racemose gland, lined with glandular epithelium, 
which forms sugar, fats, and proteids, and these are mixed with water and 
salts from the blood. The epithelial cells are so finely organized, and so 
sensitive with their minute nerve connections, that changes of atmosphere, 
changes in food, the emotions, fatigue, sickness, the catamenia, pregnancy, 
and many other influences, throw their mechanism out of equilibrium 
most readily, and change essentially the proportions of their finished 
product. Then again this delicate mechanism adapts itself to the quantity 
of its product, elaborating a smaller or a greater supply, according to the 
demand actually made upon it by the consumer. The same breast will 
either supply the proper amount of milk demanded for the require- 
ments of the average age or a greater amount for the same age in case of 
a greater gastric capacity. Again, this machinery is regulated as to the 
time which it takes to produce the average food required for the different 
ages, a shorter interval of feeding being needed for the younger infant and 
a longer one for the older. This fact is made evident by the decided 
qualitative changes which result when the gland is called upon to produce 
its product at improper intervals. Thus, a prolonged interval lessens the 
solid constituents in their proportion to the water, while a shortened in- 
terval, by exciting the epithelial cells to frequent work, over-stimulates 
them, with the result of increasing the solids in their proportion to the 
water. In fact, too long intervals produce a product too dilute, while too 
short intervals produce a product too concentrated. The analyses of 
large numbers of specimens of human milk at different periods of lactation 
show us that not only do the constituents vary from month to month, 



FEEDING. 115 

and even from day to day, but that this variation takes place as much in 
the early as in the later periods of lactation. We are not warranted, there- 
fore, in assuming that the milk grows stronger as its age increases, pro- 
vided that it still remains in normal equilibrium. The mammary gland 
acts both as a secretory and as an excretory organ, so that it cannot be 
classed as a metabolic tissue in the limited meaning which we now attach 
to these words. Yet the metabolic phenomena giving rise to the secre- 
tion of milk are so marked, so distinct, and have so many analogies with 
the metabolism which we meet in adipose tissue, that we must look upon 
the mamma chiefly as a secretory organ (Foster). This, however, is only 
within certain limits, for we know that at times foreign elements may be 
excreted from the gland. This at once suggests the interesting question 
as to when the mammary gland is most likely to have what we might call 
its normal secretory function interfered with and to assume temporarily 
the function of an excretory organ. This seems to occur both before the 
gland has attained its equipoise, as during the colostrum period, and later 
when any of the above-mentioned influences occur which affect the gen- 
eral mechanism of the gland. In these instances we find the colostrum 
reappearing in the milk. Therefore in the beginning of lactation, during 
lactation when normal metabolism is interfered with, and as lactation 
draws to a close, we have analogous conditions in which the mammary 
gland instead of being a normal secretory organ becomes abnormal and 
more or less an excretory organ. During these periods of abnormal gland 
excretion we must remember that drugs can be eliminated by the milk 
more freely than when the gland is in equipoise. We assume, therefore, 
that the mamma during that early period of lactation, which essentially 
represents a condition of lack of equipoise, has a double function, partly 
secretory, partly excretory. The greater the excretory function of the 
gland is at any time in proportion to the secretory, the more abnormal 
will be the finished product ; while the nearer the gland approaches to a 
purely secretory organ, the more perfect and normal will be its product. 
The mechanism of the mammary gland is therefore in its most perfect 
condition after the colostrum period has ceased, and at a time when the 
general organism, both physical and mental, is freed from causes detri- 
mental to a perfect metabolism. 

General principles are vital in their importance Avhen we come to 
study the subject of feeding in all its phases, whether the nutriment to be 
provided for the infant is to come directly from its mother, a wet-nurse, 
or an animal, or indirectly from the product of the mammary gland. 
These principles are, (1) That nature throughout all ages has clearly indi- 
cated by means of natural selection what the source of supply should be ; 
that' is, that the mother should during some early period of its life supply 
food for her offspring from her mammary glands. (2) That when, owing 
to disease, over-civilization, or any causes which prevent the offspring 
from receiving its sustenance directly from the maternal mammae, some 



116 PEDIATRICS. 

nutriment must be substituted which will correspond as closely as pos- 
sible to the natural food-supply. (3) That this substitution can be ob- 
tained most exactly through the product of the mammary gland of another 
woman. (4) That, owing to the strong analogy between human beings 
and all animals which suckle their young, we should in our efforts to 
copy good human milk make use not only of what we have learned 
from human beings, but also of what is known of lactation as it occurs in 
animals. This requires a knowledge of the investigations and experience 
of those who have studied commercially the breeding of animals and 
their food, and the production and modification of their milk. 

FIRST NUTRITIVE PERIOD. 

The nutrition of young human beings may be divided into three dis- 
tinct nutritive periods, corresponding to the degree of their development. 
The first period consists of the first ten or twelve months of life. The 
second period comprises the second and third years, and the third period 
the remaining years of childhood. The science of feeding depends almost 
exclusively, in addition to the general principles already referred to, on 
the knowledge of what elements of the food are required by the growing 
tissues in these nutritive periods, and also on the time when the various 
digestive functions are ready and able to dispose of them. The first 
nutritive period is essentially the only one in which human milk need be 
considered. There is a marked analogy between the nutrition of human 
beings and other mammals, and it is therefore necessary to understand 
the lactation of animals when we endeavor to explain that of human 
beings. I here wish to acknowledge my indebtedness to Mr. G. E. Gordon 
for placing at my disposal his practical observations on the feeding, 
breeding, and lactation of cows. 

The first nutritive period represents the first twelve months of life, 
and is obviously the most important one of the three. In this period 
the infant may be fed by a number of methods. It may be nursed by its 
mother, or a wet-nurse, or an animal, or it may be nourished by food 
especially prepared from the milk of one of these. 

I. MATERNAL FEEDING. 

The first of these methods, the maternal, is so far superior to any 
other which has ever been known that I shall assume that it is the best, 
and the one from which in almost every particular all others should be 
copied. 

Normal Maternal Conditions. — The assumption that the maternal is, 
when normal, the ideal source of infant food-supply presupposes many im- 
portant conditions concerning the mother and the function of her mam- 
mary glands. She should be strong and healthy, of an even, happy tem- 
perament, desirous of nursing her infant, and have time to devote' herself 



FEEDING. 117 

to this special duty during the whole period of her lactation. She should 
have a sufficient supply of milk, and should be willing to regulate her diet, 
her exercise and her sleep according to the rules which will best fit her 
for her task. These may be said to be the ideal conditions which we 
endeavor to obtain for an infant which is to be nursed under the most 
favorable circumstances. It is true that women who are far from vigorous 
nurse their infants with seemingly good results, and that a frail, delicate- 
looking mother may have an abundant supply of good milk. These are 
exceptions, however, which make the principles just stated all the more 
true. We must have some general principles to guide us in our endeavor 
to perfect the nutriment of infants as a class, or we shall surely in many 
instances do serious harm to the individual. 

Contra-Indications to Maternal Feeding. — With few exceptions, the 
mothers who have uncontrollable temperaments, who are unhappy, who 
are unwilling to nurse their infants, who are hurried in the details of 
their life, who are irregular in their periods of rest and in their diet and 
exercise, are unfit to act as the source of food-supply for their infants. 
Even if their milk happens to be sufficient in quantity, it will probably be 
so changeable in quality as to be a source of discomfort and even of 
danger rather than the best nutriment for their offspring. It is far better 
for such mothers not to attempt to nurse, but to adopt some other method 
of feeding. It is of still greater importance that mothers who are suffering 
from some chronic disease, or one which their infants may directly inherit, 
should give up all thoughts of nursing. When there is no question of 
disease in the mother, it is our duty to investigate, and, if possible, to 
counteract the other contra-indications to nursing, often only caused 
through ignorance of what to us seem very simple truths, but which to 
the young mother are enveloped in mystery. There is, then, a double 
necessity for studying in the closest detail the conditions which constitute 
normal lactation ; first, that, knowing what is normal, we should rec- 
ognize what is abnormal, and, by the intelligent use of our knowledge, 
render possible an apparently unsuccessful attempt to nurse ; secondly, 
that we may know exactly on what the normal and vital conditions of 
successful nursing depend, in order that we may understand what we 
should copy in substitute feeding. 

Nursing. — The natural method of feeding is by sucking. The infant 
should be placed in a comfortable position in its mother's arms, with its 
head and back supported. It should be made at once to understand that 
it is to begin its meal as soon as the breast is offered to it, and continue, 
with, of course, breathing-spells, until the meal is finished. The mother 
should herself preferably be sitting, as she can thus best manage and 
control the infant if it is inclined to be restless. 

The formation of the lips and buccal cavity are adapted to the 
mechanism of suction. The breast is so organized that it provides a 
fresh supply of food at the required intervals. It prevents fermentation 



118 PEDIATRICS. 

of the food before it 'enters the infant's mouth, while at the same time 
the suction incites to action both the necessary digestive fluids of the 
infant and the function of the gland itself. The gland avoids a vacuum 
by collapsing as it is gradually emptied, and allows the food to flow con- 
tinuously, thus obviating the tendency to exhaustion of the infant and 
prolongation of the nursing-time which necessarily accompanies a re- 
tarded flow of the milk. Finally, the breast is practically self-regulated 
as to the amount which it is required to provide according to the infant's 
age. A healthy infant should empty the breast with easy and uninter- 
rupted sucking in about fifteen to twenty minutes. 

Nipples. — In certain cases the mother's nipple is so small or depressed 
that it is a source of much annoyance to the infant, and at times this in- 
terferes so seriously with its obtaining the proper food-supply that its 
nutrition suffers, and some other method than nursing has to be substi- 
tuted. It is here that the ingenuity of the physician is taxed to its utmost. 
Every kind of device may fail, and it is necessary patiently to try one 
after the other before deciding to give up the nursing. Nipple-shields 
should be experimented with, and will sometimes obviate the difficulty. 
We should, however, always impress upon the mother the fact that the 
value of her milk as a food may be entirely destroyed if foreign elements 
are allowed to enter with it into her infant's mouth. This simply means 
extreme cleanliness of the glass shield and rubber nipple. 

When the nipples are very tender and cause great discomfort to the 
mother during the nursing, their condition frequently becomes so serious 
an obstacle as to prevent nursing altogether. This change, however, 
should not be thought of for at least several days, or until it is absolutely 
certain that the exquisite pain is more than the mother is willing or able 
to endure. It is often the case that after a little time of the greatest suf- 
fering from tender or excoriated nipples the whole difficulty will pass 
away and the mother be able to nurse her infant with comfort. Where 
the nipples show a tendency to be dry and hard, it is well to apply some 
simple ointment once or twice a day during the last few weeks of the 
pregnancy. Astringents, as a rule, should not be used. Bathing with 
cold water before and after the nursing, and thus keeping the tissues in a 
healthy condition, appears to be as successful as the application of any 
medicaments. 

Mastitis. — Another trouble which may arise during the nursing period 
is a disturbance of the mammary gland itself, sometimes amounting merely 
to a stasis in its milk production, but again going on to inflammation. The 
latter is a serious matter, and should at once be placed in the hands of a 
skilful surgeon. The former condition requires great care in its manage- 
ment. Gentle massage from the periphery of the gland towards the 
nipple, amounting in fact to merely a delicate stroking with the ends of 
the fingers, is an important part of the treatment. The breast should be 
withheld from the infant for about twenty-four hours, and the milk from 



FEEDING. 119 

time to time drawn in small quantities by means #f a properly adjusted 
breast-pump. The breast should also be carefully supported by a swathe. 
If these measures are begun as soon as there are any indications of dis- 
turbance in the breast, these abnormal conditions soon disappear. The 
indications referred to consist in the appearance of hard swellings in place 
of the usual soft elastic condition of the milk glands. These swellings 
may occur without any especial pain, but on palpation they are usually 
tender to a greater or less degree. 

In regard to the relation of micrococci to inflammation of the breast, 
according to Zweifel and Doderlein there are in mastitis two varieties of 
organisms, the staphylococcus pyogenes aureus and the streptococcus 
pyogenes, but never the staphylococcus pyogenes albus. They admit 
that other varieties may perhaps be found on closer investigation, but at 
the same time they consider it striking that in all their cases there were 
never any local or general symptoms caused by the staphylococcus pyo- 
genes albus, although that they were virulent was proved by their inocu- 
lation of mice. There is not much doubt that these pathogenic organisms 
gain access to the gland through the nipple. The infant may not be able 
to hold the nipple with sufficient firmness on account of some abnormal 
condition of the nipple itself. Under certain circumstances, even when 
the nipple is well formed, the infant has insufficient suction-power to obtain 
its food, though the food itself may be perfectly adapted to its digestion. In 
these cases we often find that it cannot or will not be induced to obtain its 
food through a shield and rubber nipple, as shown in the following case : 

An infant, seven months old, was dying of starvation, as I had not been able to 
prepare for it a food which it could digest and thrive on. (This was before milk 
laboratories were established.) It was totally unable to nurse, although the breast- 
milk was a good one and agreed with it perfectly when it was introduced into its 
mouth with a spoon. The milk was pumped from the breasts at regular intervals 
and given to it from a bottle for over three months with the greatest success, the 
infant thriving, and at the end of that time being in a perfectly healthy condition. 

Breast-Pump. — In regard to the use of the breast-pump there is a 
great difference of opinion, but I believe that those who have opposed its 
use have been influenced to a great degree by what they have seen in 
their hospital practice, and also by the views of others who have, in like 
manner, met with unfortunate results in lying-in hospitals. It is well 
known that all inflammatory conditions about the breast are more likely 
to occur in hospitals than under conditions in which the woman is less 
likely to be exposed to pathogenic organisms. This should be taken into 
account when we are deciding whether or not to use a breast-pump. In 
my experience, acquired in a great degree from my private practice, 
where every precaution in regard to cleanliness and asepsis could be ob- 
tained, I have never met with any bad results from the use of the pump. 
Fig. 43 represents the form of pump which I have found safe and useful. 

The apparatus should be one which can be carefully cleansed, and 



120 



PEDIATRICS. 



should, therefore, preferably be made of glass. No one special pump will, 
in all probability, suit every case, and it is of importance that one should 
use the greatest care in adapting the pump to the individual. When 

applied to the breast it should cause little 
FlG 43 or no pain or discomfort. The part 

which is adapted to the nipple is like an 
ordinary nipple-shield. This is attached 
to a glass bulb, into which the milk falls as 
it is drawn from the breast. The mechan- 
ism is very simple. A vacuum can be 
produced in v the glass bulb by means of 
suction through a rubber tube attached to 
a rubber bulb with its valve working back- 
ward. 

MILK. — The products of the mam- 
mary glands of all mammals is essentially 
the same. In all we find substances rep- 
resenting the great subdivisions of food- 
stuffs, — that is, fats, carbohydrates, pro- 
teids, and salts, — but there is considerable 
variation in the relative proportions in 
which they occur in the milk of different 
mammals, and, as regards their ultimate 
chemical analysis, much is still to be in- 
Breast-pump. vestigated by the analytical and physio- 

logical chemists. It is primarily on the 
results of their work that the advances in the scientific feeding of infants 
and children are to be made. In general the composition of milk consists 
of fats, of carbohydrates in the form of lactose or milk-sugar, of proteids 
in the form of caseinogen (casein) and lactalbumin, of salts, extractives, and 
water. It is the combination of these various elements which makes the 
resulting product characteristic of the especial mammal. 

Formation. — The more recent investigations on the physiological 
action of the mammary glands tend to show that the actually dissolved 
constituents of milk do not have their source in a simple process of filtra- 
tion or diffusion from the blood, but are dependent upon a specific 
secretory activity of the glandular elements (Hammarsten). Evidence of 
this lies in the fact that milk-sugar is not found in the blood, that the 
lactalbumin is not identical with serumalbumin, and that the mineral 
bodies exist in milk in different proportions from those in the blood- 
serum of the same animal. According to Foster, milk is the product of 
the activity of certain protoplasmic cells, occurring in the epithelium of 
the mammary gland. These cells are rich in proteids and nucleoproteids, 
which seem to be the source of the casein or its mother-substance. The 
protoplasm itself becomes a constituent of the secretion (Hammarsten). 




FEEDING. 121 

When the milk is kept at 35° C. (95° F.) outside of the body, the casein- 
ogen is increased at the expense of the lactalbumin,, When, in cows, the 
action of the cell is imperfect, as at the beginning and end of lactation, the 
lactalbumin is in excess of the caseinogen ; but when the cell possesses its 
proper activity, the formation of caseinogen is in the greater proportion. 

The fat of milk is produced within the protoplasm of the epithelial 
cells, and is set free by the destruction of the fat globules ; a portion of 
the fat is probably taken up by the glands themselves from the blood and 
eliminated with its secretion. That this is possible has been proved by the 
experiments of Winternitz, in which the passage of iodized fats in the milk 
was noted ; and similar observations were made by Spampani and Daddi 
with sesame oil. Microscopically, the fat can be seen to be gathered in 
the epithelial cell in the same way as in a fat cell of the adipose tissue, 
and to be discharged into the channels of the gland either by a breaking 
up of the cells or by a contractile extension very similar to that which 
takes place when an amoeba ejects its digested food. A formation of fats 
from carbohydrates in the animal organism is now positively proved, and 
it is possible that the milk glands themselves also produce fats from the 
carbohydrates brought to them by the blood (Hammarsten). It is also 
well established that a part of the fat of milk is produced from proteid 
material ; but the question in all these instances as to how much fat is 
produced by the secretory mechanism of the milk glands, and how much 
is obtained from other organs and tissues and eliminated from the blood 
by the milk glands, has not been determined. 

The origin of the milk-sugar is not known. That it is formed in the 
cell protoplasm is indicated by the fact that it is not found in the blood 
itself, and may be maintained in abundance in the milk of carnivora 
which are fed exclusively on lean meat. One of the nucleoproteids men- 
tioned above as occurring in the cell protoplasm yields a reducing sub- 
stance when boiled with dilute acids, and future investigations may show 
some relation between this substance and lactose. 

Nervous Disturbances affecting the Milk. — The secretion and elimi- 
nation of milk are very evidently under the control of the nervous system, 
which produces marked changes in both the quantity and the quality of the- 
mammary product in proportion to the relative nervous excitability of the 
special mammal. Women are especially sensitive in this respect, and when 
living in the midst of our modern civilization, so harmful for the produc- 
tion of good nursing, present an exaggerated example of disturbance of 
the equipoise of the mammary gland. The chemistry of the equipoise 
and lack of equipoise of the mammary product appears to be closely con- 
nected with its proteid element. This element is known to be a com- 
pound one and decidedly complex, but for purposes of illustration we can 
safely say that the word proteid is a general term, which includes casein- 
ogen and lactalbumin ; also that these factors of the complete whole vary 
in their proportions to each other according as the mammary function is or 



122 PEDIATRICS. 

is not in a state of equipoise. In the colostrum period, and probably in 
the analogous periods represented by the abnormal conditions already 
spoken of, the lactalbumin is in excess in proportion to the caseinogen, 
while as the equipoise of the function becomes more complete the casein- 
ogen is increased proportionately to the lactalbumin. Probably at the end 
of lactation, as in the beginning, we shall find this same condition of rich- 
ness of lactalbumin and deficiency of caseinogen. This increase of the 
the lactalbumin at the expense of the caseinogen explains how the excretory 
function of the gland at times becomes more prominent than the secretory. 

These nervous disturbances, however, may also cause an over-produc- 
tion of the total proteids, as shown by their percentages. In some cases 
also the fat has been found to be much reduced in its total percentage. 
Instances of this have arisen when, as observed by Zukowski, seasons of 
fasting with their accompanying excitement of the emotions have induced 
such a disturbance of the equilibrium of the milk that the fat has been 
found to be decreased to the low percentage of 0.88, with the result that 
the infant has become sick and given evidence of impaired nutrition. 
These same nervous influences in all probability have to a greater or less 
degree their analogy in the milk-product of all mammals. 

COLOSTRUM. — During the early days of lactation the mammary 
gland secretes a fluid which differs somewhat from that which is produced 
later. The milk at this period is called colostrum, and the period is called 
the colostrum period, on account of the presence in the milk of certain ele- 
ments called colostrum corpuscles. These cells measure from 12 to 22 ^ 
in diameter, and show a small, irregular, extensively degenerated nucleus. 
Their protoplasm contains large and small granules, which show the pro- 
teid reactions, and are not stained by acid, basic, or neutral dyes ; a few 
of the granules which stain by osmic acid are probably fatty. The cor- 
puscles have been described by Czerny as lymphoid cells, whose function 
is to absorb and reconstruct unused milk globules and to convey them 
from the milk glands into the lymph-channels. They disappear from the 
mother's milk in a week or ten days after birth. If they continue in the 
milk into the third week, or return at any time during lactation, they almost 
invariably cause disturbance of the infant's digestion, and become an indi- 
cation for a temporary suspension of nursing. If they persist for any 
length of time, the mother's milk is manifestly not suitable for the infant, 
and a substitute should be provided. 

Chemistry. — An analysis of colostrum milk of a cow by Harrington 
gave the following results : 

Fat 1.71 

Milk-sugar 4.90 

Proteids".. 1.72 

Ash , 0.79 

Total solids , 97l2 

"Water 90.88 

100.00 



III. 


IV. 


Y. 


2.40 


5.73 


4.40 


11.15 


10.69 


11.27 


0.25 


0.16 


0.21 


13.80 


16.58 


15.88 


86.20 


83.42 


84.12 



FEEDING. 123 

The table which follows represents the analyses of five specimens of 
duman colostrum milk, also made by Harrington : 

TABLE 24. 

I. II. 

Eat 1.40 0.68 

Milk-sugar and proteids ... 9.44 11.53 

Ash 0.17 0.31 

Total solids 11.01 12.52 

Water 88.99 87.48 

100.00 100.00 100.00 100.00 100.00 

The most recent study of human colostrum has been made by Wood- 
ward, who analyzed the colostrum of six nursing women, using in each 
instance the combined twenty-four hours' amount of the middle milk, 
and following each case from three to seven days. He concludes as a 
result of his investigations that colostrum corpuscles are not always 
found in the so-called colostrum-milk ; that when they are present the 
percentage of proteids is higher, and as they disappear the proteid per- 
centage drops. In all his cases there was a loss of weight in the infants 
varying from eight to twelve ounces, whether the colostrum corpuscles 
were present or absent ; when they were absent a high temperature in 
the mother was noted. The results of his analyses may be best seen 
in the following table : 

TABLE 25. 

General Average of 
Twenty -six Analyses. 
Color Yellowish. 

Keaction Alkaline. 

Specific gravity 1024 to 1034. 1029. 5 

Eats 2.0 to 5.3 per cent. 4.0 per cent. 

Proteids 1.64 to 2.22 per cent. 1.9 per cent. 

Ash 0. 14 to 0.42 per cent. 0.2 per cent. 

Total solids 10. 18 to 13. 65 per cent. 12. 5 per cent. 

Lactose (calculated) 5.6 to 7.4 per cent. 6.5 percent. 

Water 87.5 per cent. 

The observations of Townsend have shown that the infants of mul- 
tiparas do not lose as much weight in the colostrum period as those of 
primiparae, and also that the shorter the colostrum period the smaller the 
so-called physiological loss of weight in the new-born. 

Colostrum is also supposed to have a laxative effect, and so to aid in 
removing the meconium. Whether this action is of any advantage to the 
infant is doubtful. The appearance of the colostrum corpuscles is simply 
an indication that the equilibrium of the mammary gland has not been 
established, or has been disturbed. It may be that the not infrequent 
disturbance of the infant's digestion in the early weeks of nursing is pro- 
duced by an exaggerated abnormal condition occurring in the colostrum 
period, as well as by the return of the colostrum at irregular intervals. 



124 PEDIATRICS. 

HUMAN MILK. — Beyond the general conditions affecting the 
mammary products of the mother, which have already been spoken of, I 
know of no way of increasing the flow of milk. I have little confidence 
in galactagogues in the form of drugs or special foods, for their number 
betrays their inefficiency. The milk becomes lessened from many causes, 
some of which are identical with those which commonly produce any dis- 
turbance of its equilibrium such as have been mentioned. Certain drugs, 
such as belladonna, will in some women cause a notable decrease in the 
flow of milk, and must therefore be given with care during the nursing 
period. An active cathartic, and also a diet composed of solid food and 
a small amount of water, will also lessen the quantity of milk. 

Clinical Examination of Human Milk. — The quality of the mother's 
milk is of so much importance to the welfare of the infant that it is of 
the greatest practical assistance in the management of certain cases to 
know the results of an analysis of the breast-milk. This can be done 
exactly only by an analytical chemist. The methods of analysis used 
is too purely a chemical question to be of practical use in clinical work, 
but simple approximate clinical tests are often very desirable, even 
though they are less accurate, when the services of a skilled chemist 
cannot be obtained. 

To obtain a specimen for analysis the hands should be sterile, the 
breast and nipple should be carefully washed with sterilized water, and 
from 20 to 30 c.c. (5 to 8 drachms) of milk drawn by the breast-pump, 
which, being made of glass, can also be thoroughly washed. The milk 
should then be poured into a sterilized bottle, tightly corked, and kept on 
ice until the examination is made. 

The general methods of making the rough quantitative estimation of 
the constituents of the milk are as follows : 

Specific Gravity. — This is obtained by means of the hydrometer, for 
the use of which only 15 c.c. (J ounce) of milk are required. 

Pats.- — In every case it is very important to know the exact percent- 
age of the fat, both from its being the most variable element and from its 
use in the determination of the percentages of the other elements. The 
most exact means for this purpose outside of the chemical laboratory is 
an apparatus called the Babeoch Fat-Tester, which is shown in Fig. 48,. 
and described on page 192. As this is not an expensive machine, it has 
seemed to me that in communities at a distance from an expert chemist, 
or where the people are unwilling to pay for a complete analysis, a Bab- 
cock machine could be owned jointly by a number of physicians and 
kept at some central place. The smallest amount of milk required for 
determining the percentage of fat with the Babcock machine is 17.50 c.c. 

Another less accurate method of estimating the percentage of cream is 
by means of Holt's cream-gauge. 

A glass-stoppered graduated cylinder is filled with milk exactly to the 
upper line, which is marked 0. A pipette should be used for putting the 



FEEDING. 125 

last few drops into the cylinder, care being taken not to allow the milk to 
run down the inner side of the tube, since this somewhat obscures an exact 
reading. The cylinder is then corked and allowed to stand for twenty- 
four hours at a temperature as near to 21.1° C. (70° F.) as is practicable. 
A variation of a few degrees on either side of this point is unimportant. 
If, however, the variations are wide, the rapidity with which the cream 
rises is somewhat modified. In the great majority of cases the lower line 
of the cream has become sharply defined at the end of twenty-four hours, 
and can then be recorded. If this is not the case, the milk should be 
allowed to stand for six hours longer before reading the percentage. By 
comparing the percentage of the cream with that of the fat, as determined 
by a chemical analysis of the same specimen, it has been discovered that 
the ratio of the cream to the fat is very nearly 5 to 3, — that is, 5 per 
cent, of cream in the cream-gauge will indicate that the milk contains 3 
per cent, of fat. 

Proteids. — There is no known method of determining directly the per- 
centage of the proteids in the milk by a clinical examination, and a com- 
plete chemical analysis by an expert is the only one that can be accepted 
as accurate. It is possible, however, from a knowledge of the specific 
gravity and the percentage of the fat, to make an approximate calculation 
in regard to the percentage of the proteids, at any rate sufficiently close to 
determine whether in a given case they are near the normal, or are in very 
large or very small proportions. Holt has described a method in which 
the only instruments needed are a small hydrometer, a pipette, and a glass- 
stoppered cylinder graduated to one hundred parts and holding about 10 c.c. 

The specimen of milk for analysis should be taken from the " middle 
milk,' 1 and it is important that the milk should be freshly pumped and 
handled as little as possible, also that the graduated glass cylinder should 
be scrupulously clean, otherwise the milk will often sour before the cream 
has had time to rise. This is particularly true in summer. 15 c.c. (f 
ounce) is the amount of milk required for the test. 

In estimating the proteids certain suppositions must and can be fairly 
accepted : 

(1) Supposing the proteids to remain unaltered : if the percentage of 
fat be low, the specific gravity will be high, but if high, the specific gravity 
will be low. 

(2) Supposing the fat to remain unaltered : if the percentage of the 
proteids be high, the specific gravity will be high, but if the percentage of 
the proteids be low, the specific gravity will be low. 

If, therefore, the fat and the specific gravity be known, the proteids 
may be estimated by the following rules : 

(1) If the percentage of the fat be found to be high and the specific 
gravity high, that is, from 1033 to 1034, we may assume that the proteids 
are also of high percentage, otherwise the excessive fat would bring the 
specific gravity below the normal average. 



126 PEDIATRICS. 

(2) If the fat be found to be of low percentage and the specific gravity- 
high, we may assume the proteids to be nearly normal, since the high 
specific gravity is explained by the small proportion of fat. 

(3) If the percentage of fat be high and the specific gravity low, the 
proteids may be assumed to be normal, since the variation in the specific 
gravity is explained by the high percentage of fat. 

(4) If the percentage of fat be low and the specific gravity low, the 
percentage of the proteids is also low, since otherwise the small propor- 
tion of fat would make the specific gravity above the average. 

Of course it is only the wide variations in the proteids which can 
be recognized by these rules ; but these variations are often very impor- 
tant. 

We can then say that, knowing the specific gravity, and calculating the 
fats as three-fifths of the known percentage of the cream, we can judge 
whether the proteids are normal, very high, or very low in amount. 
Whereas only wide variations can be recognized by these rules, even these 
are often very useful. Holt asserts the estimation of the proteids of milk 
by this method to be as accurate as the estimation of solids by the specific 
gravity in examinations of the urine. 

Another method of estimating the percentage of proteids has been 
recommended by Woodward. Two " milk-burettes," each of a capacity of 
10 c.c, having a glass pinch-cock or valve and a narrow exit-tube about 
one inch long, each containing 5 c.c. of milk, are subjected to a tempera- 
ture warm enough rapidly to sour the milk— 35° to 37.8° C. (95° to 100° 
F.). They are allowed to remain in this temperature until a distinct pre- 
cipitate can be seen, which is in from eighteen to twenty-four hours. At 
the end of this time the milk has distinctly separated into an upper layer 
of viscid yellow fat, and a lower layer of fluid milk, quite opaque above, 
transparent below, and clinging to the sides of the tube. At the bottom 
there is a granular precipitate. The burettes are then cooled in water, the 
milk serum withdrawn into two graduated tubes, and 10 c.c. of Esbach's 
solution (picric acid, 5 gm. ; citric acid, 10 gm. ; water, 500 c.c.) is added 
up to the 15 c.c. mark. The mixture is then stirred with a glass rod and 
placed in a hand centrifuge. The amount of centrifugation required is 
in direct proportion to the care used in separating the fat, and should 
be continued until there is a constant reading. This can be quickly ac- 
complished if the fermentation of the milk in the tubes is watched and 
the separation of the casein is made as soon as the precipitation is formed. 
The reading expresses in percentage the amount of total proteids in the 
milk. 

Sugars and Salts. — These may for clinical purposes be assumed to 
be about constant in all human milk, and in fact are practically shown to 
be by a large number of exact chemical analyses. 

Microscopic Examination. — The mere microscopic examination of milk 
beyond the determination of the presence or absence of colostrum cor- 



FEEDING. 127 

puscles and foreign matters, such as pus, blood, and epithelial cells, is too 
uncertain and misleading to be in any way depended upon, the chemical 
analysis being the only practical method which can be recommended. The 
truth of this statement was lately impressed upon me when a physician 
skilled in the use of the microscope sent me a specimen of woman's milk 
which he stated was rich in fat, but which the analysis showed to have 
only a little over one and a half per cent, of this element. 

The presence of an undue amount of yellow coloring matter is at times 
very misleading. I have also seen human milk which had a greenish color, 
evidently produced by some of the micro-organisms which are known to 
occur in cow's milk, but the nature of which is not yet fully determined 
and which under the microscope are not represented by anything abnor- 
mal. 

CLINICAL SIGNIFICANCE OF THE CHEMISTRY OF HUMAN 
MILK. — There is no doubt of the great value of an expert chemical ex- 
amination of the milk in cases where an infant is not thriving, although 
apparently receiving a sufficient quantity of milk from its mother. On 
the other hand, we must remember that a chemical analysis will never 
give any information regarding the quantity of the milk, and it often hap- 
pens that when such an analysis has proved the quality to be good, the 
infant is not thriving because the quantity of the milk is very small. The 
symptoms which indicate that it is the quantity of milk which is at fault 
rather than the quality are that the breasts at the nursing time are soft, 
and that only a small quantity of milk can be extracted from them by the 
breast-pump. A period of nursing longer thau the usual fifteen to 
twenty minutes before the child is satisfied should make us suspicious that 
the milk is lacking in quantity. We can also determine the actual quan- 
tity of the milk which the child has imbibed at an especial nursing by 
means of Aveighing, as described on page 59. A number of observations 
at different nursings in the day must, however, be made before a correct 
conclusion can be reached by this latter procedure. 

Konig, Forster, Meigs, Harrington, and others have analyzed the milk 
of a large number of women of all nationalities. An average of their 
results is expressed in the following table : 

TABLE 26. 

Average Human Milk. 

Reaction Amphoteric or slightly alkaline. 

Specific gravity 1028 to 1034. 

Water 87 to 88 per cent. 

Total solids 12 to 13 per cent. 

Fats 3 to 4 per cent. 

Milk-sugar 6 to 7 per cent. 

Proteids 1 to 2 per cent. 

Total mineral matter 0.1 to 0.2 per cent. 

Reaction. — According to Hammarsten, woman's milk is amphoteric 
in reaction instead of alkaline. Courant has shown bv delicate chemicai 



128 PEDIATRICS. 

tests that the relation between the alkalinity and acidity in breast milk is 
as 3 to 1. 

Specific Gravity. — The specific gravity varies normally to a consider- 
able degree on account of the variations in temperature to which the 
milk happens to be exposed at the time when the specific gravity is taken. 
When, however, the milk has its average normal composition, and the 
temperature to which it is exposed is 15.5° C. (60° F.), its average spe- 
cific gravity is 1031. 

"Water. — One of the most important chemical facts to be remembered 
for clinical purposes is the very large proportion of water which is found 
in normal human milk, for it shows it to be a highly diluted food by which 
the best results can be obtained in infant feeding. It also indicates the 
care that should be taken not to overtax the comparatively slight power 
of absorbing a concentrated food which exists in the early months of life. 

Fat. — The fat of human milk is made up chiefly of palmatin, stearin, 
and olein. About two per cent, of the total fat consists of the glycerides 
of butyric, caproic, caprylic, and myristic acids. The production of animal 
heat is so very important a part of the infant's well-being that it is not sur- 
prising we should find so large a percentage of fat as well as of sugar in the 
food which is provided for it. The presence of fat in the milk is not only 
for the purpose of nutrition, but also as a means for the maintenance of 
bodily heat. This latter function of the fat cannot with impunity be trifled 
with, and is essential for active metabolism. A proper amount of fat is 
probably of great aid in the regulation of the faecal discharges. An amount 
of fat proportionate to the proteids is presumably necessary, or at least of 
great aid, in their proper digestion. We should naturally expect that unless 
the standard percentage of fat, or at least a near approach to it, existed in 
the mother's milk, trouble would be likely to arise with her infant, and this 
corresponds with my experience in cases in which the special ingredient 
which has interfered with the success of the nursing has been the fat. I 
have found clinically that when the fat was much lessened the nutrition 
suffered, that the digestion was not good, and that there was a tendency to 
constipation, while when its percentage was decidedly above the standard 
the digestion was weakened, there was a tendency to diarrhcea, and in con- 
sequence a resulting poor nutrition. 

These clinical observations at once suggest that in the management 
of infant feeding we must recognize the existence of two important con- 
ditions. One of these is the digestion of the infant, the other is its nutri- 
tion. These two requirements for a successful lactation are based on the 
facts that the milk may be easily digested but not nutritious, and that it 
may be highly nutritious but difficult to digest, .so that it is the equilibrium 
of these two conditions which produces a perfect infantile development. 
It is especially important that the percentage of fat in an infant's food 
should be within the limits of the normal variations which are found in 
the milk of healthy nursing women with healthy infants. For, although 



FEEDING. 129 

it is admitted that a large percentage of surplus fat is frequently found in 
the faeces of infants whose digestion and nutrition are normal, and whose 
food is human milk, yet we have no more right to conclude from this that 
a small percentage of fat is sufficient for nutrition, or that a large surplus 
will be eliminated by the faeces, than Ave have to assume that there is too 
much oxygen in the blood because we find a certain surplus of oxygen in 
the blood which is returned to the lungs in the venous circulation. In 
fact, it is far more probable that nature introduces a certain percentage 
cf fat into human milk with a purpose which can be accomplished only 
by that percentage, so that it is an error to change this percentage beyond 
the variation which commonly occurs in average human milk. 

Sug-ar. — The form of sugar which is found in human milk is called 
milk-sugar, or lactose, and has the highest percentage of all the elements 
constituting the total solids of the milk. The sugar is more digestible than 
the fat, but does not have so much potential energy — that is, so much 
heat-producing power in a given weight — as does the fat, which is to the 
sugar as 2.4 to 1. The conversion of milk-sugar into lactic acid gives rise 
to many of the changes occurring in milk. 

Proteids. — Although there have been a great many different opinions 
expressed as to the average percentage of the total proteids in human 
milk, we are led at present to believe that it is normally one or two per 
cent. Proteid is a general name including caseinogen and lactalbumin, 
which in its general features resembles ordinary serum-albumin, but the 
ultimate chemistry of these elements is still obscure. We recognize that 
this lactalbumin is present in small and variable quantities when the 
mammary gland and its secretion are in a normal condition, while at the 
time when the glandular function is being established, and during periods 
of glandular disturbance, it becomes proportionately larger in amount. 
According to Konig, who, in his comparative analysis of the caseinogen 
and lactalbumin in human milk, estimates the total proteids at 1.82, the 
caseinogen has a percentage of 0.59, while the lactalbumin is 1.23, and 
other analyses show a greater proportion of caseinogen than this. The 
proteids, as a whole, are a valuable source of information to us when we 
are determining whether the milk is normal or abnormal, and in arranging 
an infant's food the relative proportions of the caseinogen and lactalbumin 
should be borne in mind. 

Mineral Matter. — The mineral matter, which is sometimes called the 
ash and sometimes the salts, has an average percentage of from 0.1 to 0.2. 
Up to the present time, although a certain number of analyses of the min- 
eral matter of human milk have been made, yet the results, for various 
reasons, have been deemed unsatisfactory. So large a quantity of milk is 
needed for a reliable determination of the percentage of each element 
which makes up the total amount, that this in itself has been an important 
reason for failure in accuracy. The determination of the mineral matter 
of cow's milk has not been attended with the same difficulty, and its per- 

9 



130 PEDIATRICS. 

eentages have been estimated with comparatively reliable results. It has 
always been supposed that there is a radical difference between the per- 
centages of the mineral matter of cow's milk and that of human milk. The 
exact knowledge of the percentages which exist in the latter has become 
of still greater importance since such decided advances have been made in 
the modification of the elements of the former. With the view of making 
some advance in this difficult question, and of providing for the milk- 
modifiers of the future a more exact basis for perfecting a substitute food 
resembling as closely as possible the product of the human breast, I un- 
dertook, in the spring of 1893, to procure an unusual and sufficient 
quantity of human milk for analytical purposes. In the course of a few 
weeks, by means of the concerted action of numerous assistants, I col- 
lected five and a half liters (about six quarts) of human milk, which is an 
unusually large quantity for experimental purposes. This milk was im- 
mediately reduced to its mineral constituents in the laboratory of Dr. 
Charles Harrington. The analysis of this large amount of mineral matter 
was then made by Dr. Harrington and Dr. L. P. Kinnicutt, with the fol- 
lowing results : 

The Mineral Matter of Human Milk. 

Unconsumed carbon 0. 71 

Chlorine 20. 11 

Sulphur 2.19 

Phosphoric acid 10. 73 

Silica ......._ 0. 70 

Carbonic acid 7.97 

Iron oxide and alumina 0. 40 

Lime 15.69 

Magnesia 1.92 

Potassium 24. 77 

Sodium 9. 19 

Oxygen (calculated) 6.16 

100.54 

Composition of the Mineral Matter calculated from the above Analysis. 

Uncombined carbon 0. 71 

Calcium phosphate 25. 35 

Calcium silicate 1.35 

Calcium sulphite 2.11 

Calcium oxide 1. 72 

Magnesium oxide 1.91 

Potassium carbonate 24.93 

Potassium sulphite 8.04 

Potassium chloride 12. 80 

Sodium chloride . 23. 13 

Iron oxide and alumina 0. 40 

102.45 

A closer approximation to the relative proportions of the salts in the 
form in which they occur in milk, calculated from the above analysis, may 
be stated as follows : 



FEEDING. 131 

Calcium phosphate 23. 87 

Calcium silicate 1.27 

Calcium sulphate 2.25 

Calcium carbonate 2.85 

Magnesium carbonate 3.77 

Potassium carbonate 23.47 

Potassium sulphate 8.33 

Potassium chloride 12.05 

Sodium chloride 21.77 

Iron oxide and alumina 0.37 

100.00 



In comparing the previous analyses which have been made, and which 
can be found in Konig's Nahrungsmittel, II. , 2 e Auflage, with this new 
analysis, we must remember that the previous analyses were made some 
years ago. In the last few years the processes which have been employed 
have been so much more exact that these results must be considered far 
more trustworthy than those made at an earlier date. It is not remark- 
able, therefore, that distinct differences should be found between this 
new analysis and the analyses which have hitherto been made, and pre- 
sumably this last analysis is the correct one. It has been made with 
the greatest care, and by means of the most improved technique, by two 
eminently competent and well-known chemists, who in their work have 
acted as controls on each other. In this way great precision has been 
attained. 

The residue obtained from the evaporation of about six quarts of 
woman's milk was extracted with naphtha to remove the fat, and then 
ignited at a very low temperature so as to prevent the volatilization of 
the chlorides. The ignition was accomplished by placing the residue from 
the naphtha extraction in a platinum dish which was supported on a 
platinum coil inside of a larger platinum dish, the latter being heated with 
a free flame. Even at this low temperature a partial change in the com- 
position of the ash took place, the sulphates being reduced to sulphites,, 
but not to sulphides, as the ash on being carefully tested showed that 
sulphides were not present. All the carbonates of calcium and all the 
carbonates of magnesium were reduced to oxides. The ash also contained 
seven-tenths of one per cent, of unconsumed carbon. 

In woman's milk, naturally, there would be no free carbon. All the 
calcium that did not exist as phosphate would be in the form of sulphate 
and carbonate, not of sulphite and oxide as found in the ignited ash. 
The magnesium would exist as carbonate, not as oxide, and the potassium 
as sulphate, carbonate, or chloride. No sulphite of potassium would be 
present. 

The chief differences between this new analysis and all previous ones 
are as follows : 

(1) The phosphoric acid is less than half as much as previously re- 
ported. 



132 PEDIATRICS. 

(2) The magnesium is also less than half as much. 

(3) Silica and alumina are present. They have not been returned in 
any previous analysis. 

Assuming the truth of the statement that the constituents of the 
mineral elements of human milk are subject to great fluctuation according 
to age and other causes, it is right to assume that the mineral matter ex- 
amined by Harrington and Kinnicutt, being the product of a large number 
of women, is a fair average specimen. 

The conclusions which we can draw from these chemical analyses are 
far from precise, owing to the variations which may occur and to the in- 
sufficient number of reliable analyses which have so far been made, but 
they enable us to work more intelligently. 

Variations in Milk. — We are led to expect that we shall find that 
when the milk is poor and does not agree with the infant there is an 
excess of proteids and a diminution of fat beyond what we have so far 
been able to determine as the normal average percentages of these two 
elements. Again, when a variation takes place in the milk it is more 
likely to be found in the fat and proteicls, as already stated, than in the 
sugar or the mineral matter. It is also important to have a number of 
analyses made, on different days and at different times, in order that the 
error of an especial or temporary variation may be corrected. The im- 
portance of the assistance which can be gained from these analyses is, in 
my opinion, very great, and many more analyses should be made than we 
are now in the habit of deeming necessary. The question of expense 
should not for a moment be considered by those who can afford to have 
analyses made, for not only will real benefit come to their own children 
through money spent in this way, but these analyses, when published and 
collated, will prove of great value for the proper regulation of the feeding 
of infants in all classes of society. An error for which we must always 
allow may interfere with the true analysis of the milk which the infant 
has actually received in its stomach at the end of the nursing, and is one 
which must necessarily invalidate the information which we receive from 
our analysis. This subject has already been referred to in speaking of 
the changes which arise from slight causes and influence the special 
specimen which is being analyzed. Thus, we should recognize that the 
milk varies considerably in its percentage of fat and total solids in the 
different periods of a nursing, and that the composition of the milk which 
the infant has in its stomach may differ very widely from the composition 
of a specimen taken directly before or after the nursing. Harrington's 
analyses of the three periods of a milking will illustrate the meaning of 
what has just been said, and although they were made from the milk of a 
cow, yet knowing the closely analogous conditions existing in human and 
in animal milk, we shall find them equally valuable in explaining the 
corresponding changes met with in woman's milk. They are represented 
in this table (Table 27) : 



FEEDING. 133 

TABLE 27. 

Fat. Total Solids. Water. Mineral Matter. 

"Fore-milk" 3.88 13.34 86.66 0.85 

"Middle milk" 6.74 15.40 84.60 0.31 

"Strippings" 8.12 17.13 82.87 0.82 

Reiset and Peligot have also made analyses of the first, second, and 
third portions of ass's and cow's milk, with the result of showing not 
only the increase of solids at the end of a milking, but also that this in- 
crease is mostly of the fat, and to a lesser degree of the proteids, and that 
a short interval of nursing increases the solid constituents in proportion 
to the w^ater, the reverse of this being true when the intervals are long. 
Heidenhain explains this physiological phenomenon by saying that his in- 
vestigations point towards the fact that during the pauses between the 
milkings the cells of the glands are growing. During this time a propor- 
tionately small amount of solids and a proportionately large amount of 
w-ater are secreted, while the irritation of milking causes increased activity 
of the milk-cells, with a corresponding increase in the solid secretion and 
a lessening of the water. 

Harrington's analyses of woman's milk showing the ,; strippings" of 
a tw T o-hours interval and the " fore-milk" of a twelve-hours interval are 
also of considerable interest : 

"Strippings," 'Fore-Milk." 

2-hours Interval. 12-hours Interval. 

Total solids 15.32 10.14 

"Water 84.68 89.86 



100.00 100.00 

With these chemical and physiological facts before us, we are forced to 
acknowledge that we must be very circumspect in the conclusions which 
we deduce from such analyses of human milk as have been made up to 
the present time. An error in these conclusions, when a correct chemical 
analysis has been made, is less likely to occur from the sugar and the 
mineral matter than from the proteids and the fat. 

Reasoning from the strong analogy which must exist between human 
milk and cow's milk, and being aware of the great variations which occur 
in the latter, w^e may assume that human milk is liable to vary in its com- 
position considerably with different milkings on the same day, and also with 
the milkings of the same hours on different days, so that at present we are 
not in a position to state that our knowledge of human milk is sufficiently 
exact to justify an attempt to formulate a table to show r the composition of 
woman's milk at different periods of her lactation, however valuable such 
information may in the future prove to be. We must also understand that 
human milk of normal quality, and proving to be equally nutritious to the 
special infants that are fed on it, may vary considerably in the percentages 
of all its elements, and in the combinations of these percentages. This fact 
is w T ell illustrated in the following table, showing the analyses of fourteen 



134 PEDIATRICS. 

specimens of human milk all differing in the combinations of their dif- 
ferent elements : 

TABLE 28. (Harrington. ) 

Human Breast-Milk Analyses. 

[Mothers healthy, and infants all digesting well and gaining in weight. ) 

I. II. III. IV. V. VI. VII. 

Per Cent. Per Cent. Per Cent. Per Cent. Per Cent. Per Cent. Per Cent. 

Eat 5.16 4.88 4.84 4.37 4.11 3.82 3.80 

Milk-sugar 5.68 6.20 6.10 6.30 5.90 5.70 6.15 

Proteids 4.14 3.71 4.17 3.27 3.71 1.08 3.53 

Mineral matter . 0.17 0.19 0.19 0.16 0.21 0.20 0.20 

Total solids. ... 15.15 14.98 15.30 lTlO 13.93 10.80 13.68 

Water 84.85 85.02 84.70 85.90 86.07 89.20 86.32 

loo. 00 100.00 100.00 100.00 100.00 100.00 100.00 

VIII. IX. X. XI. XII. XIII. XIV. 

Per Cent. Per Cent. Per Cent. Per Cent. Per Cent. Per Cent, Per Cent. 

Eat 3.76 3.30 3.16 2.96 2.36 2.09 2.02 

Milk-sugar 6.95 7.30 7.20 5.78 7.10 6.70 6.55 

Proteids 2.04 3.07 1.65 1.91 2.20 1.38 2.12 

Mineral matter 0.14 0.12 0.21 0.12 0.16 0.15 0.15 

Total solids 12.89 13.79 12.22 10.77 11.82 10.32 10.84 

Water 87.11 86.21 87.78 89.23 88.18 89.68 89.16 

100.00 100.00 100.00 100.00 100.00 100.00 100.00 

All these specimens of milk were obtained from healthy mothers, and 
in every case the infant was thriving. In a number of these cases, how- 
ever, when one of the infants which was doing well on its own mother's 
milk was fed with one of the other combinations, it soon became sick, and 
had to be changed back to the one adapted to its digestion. Human milk 
may, then, be considered to represent not an especial food but a combina- 
tion of foods, and its fat, sugar, proteids, and mineral matter to represent 
these different foods. In other words, we find by experience that the 
digestive capabilities of infants differ, just as do those of adults, and that 
nature provides a number of varieties of good human milk adapted to the 
varying idiosyncrasies of infants. 

BACTERIOLOGICAL EXAMINATION.— Although human milk is 
usually considered to be sterile, except in some cases in which the woman 
is diseased, yet Cohn and Neumann have examined the milk of forty-eight 
healthy women and have found bacteria in forty-three cases. These or- 
ganisms were mostly represented by the staphylococcus pyogenes albus, 
with a few of the staphylococcus pyogenes aureus and the streptococcus 
pyogenes. They found fewer bacteria when the breast had been emptied 
a short time previously, and more when there had been a stagnation of 
the milk in the breast. More bacteria were also found in the first few 
drops than in the last ones, and from their experiments they concluded 
that the bacteria enter the nipple from without. The conclusions deduced 
from their experiments, as well as from the experiments of others who 
have met with similar results, seem to show practically that bacteria can 



FEEDING. 135 

enter the ducts of the nipple and penetrate to a greater or less distance ; 
also that the milk in its course from the gland to the nipple washes out 
the bacteria, and that we can in this way account for the presence of these 
organisms in the milk which is first drawn from the breast, and their 
absence from that which comes later. 

MANAGEMENT OP POOD IN EARLY DAYS OF LIFE.— 
Young animals at birth begin to receive their nourishment immediately, 
and a corresponding increase in their weight takes place from the first day 
of life. The human infant in like manner should begin with its nursing 
early, getting what it can from the breast until the full supply of milk has 
come. In this way it will not be so likely to have a large initial loss of 
weight to regain, a condition by which it is often handicapped at the very 
beginning of its career, when there is most danger to be apprehended from 
a depression of its vitality. Every day, every hour, is of the utmost im- 
portance in the early days of life, and provided it can be done without 
detriment to the condition of the mother, the sooner the infant is put to 
the breast the better it will be. During the first twelve hours of life, and 
in most cases during the first twenty-four to thirty-six hours, owing to the 
inability of the mother to supply milk for her infant, scarcely any food is, 
as a rule, obtained. If during this period the infant is restless and evi- 
dently hungry, 5 to 10 c.c. (1 to 2 drachms) of a sugar solution may be 
given at intervals of two or three hours. This solution should be made 
by dissolving milk-sugar in sterilized water, and its strength should be 
from five to six per cent. If the mother's milk is delayed still longer, 
something additional must be given to the infant, and in these cases the 
following prescription is useful : 

Prescription 2. 

Fat 1.00 

Sugar 5.00 

Proteids 0.50 

Keaction slightly alkaline. 
10 feedings, each 30 c.c. (1 ounce). To be heated for thirty minutes at 75° C. (167° F.). 

Intervals of Feeding. — The younger the infant the greater the meta- 
bolic activity, and hence the greater need of frequent feeding, for food is 
required not only for repair of waste, but also for the infant's rapid pro- 
portionate growth. This, with the increased demand for additional animal 
heat, makes essential the regulation of the intervals of feeding according 
to the age. 

The intervals constitute a very important part of the management of 
breast feeding, when the quantity is regulated by the breast itself. These 
intervals should be definitely stated to the mother at different times 
throughout the nursing period, and should be adhered to. The following 
table represents the intervals for an average breast-fed infant, but it should 
be understood that the intervals of feeding should be made to correspond 
to the. stage of development of the individual. 



136 PEDIATRICS. 

TABLE 29. 

The day feedings are supposed to begin at 6 A.M. and to end at 10 P.M. 



fnrx 


Age. 

i birth to 4 weeks .... 

4 to 6 " 

6 to 8 " 

2 to 4 months 

4 to 10 " 

10 to 12 " 


Intervals. 
. . . . 2 hours 


Number of 
Feedings in 
24 hours. 
10 


Number of 
Night Feedings. 

1 


(< 


.... 2 " 


9 


1 


a 


2i " 


8 


1 


ti 


2i " 


7 





(< 


3 " 


6 





u 


....3 " 


5 






When the milk has begun to be produced in the breast, the infant 
should be fed once in two hours during the day and once during the night 
until it is six weeks old. The day feedings are usually reckoned from 6 
a.m. to 10 p.m. This interval of two hours should be adhered to, allowing 
that exceptional circumstances may arise in which the physician must judge 
according to the individual case, until the sixth or eighth week is reached, 
when the intervals may be made two and one-half hours, and the number 
of feedings in the twenty-four hours eight. At about the fourth month 
the intervals can be made three hours, and the number of feedings six. 
When the infant is two or three months old, the night feeding can be 
omitted. The number of feedings at ten months may be reduced to five. 
Allowing the mother to have as many hours of continuous sleep at night 
as possible is especially important, in order that she may not be exhausted 
by the lack of that regular and sufficient rest which is of the utmost 
necessity for the production of a normal milk. 

Irregularity in nursing, too frequent nursing, and too prolonged inter- 
vals often so disturb the quality of human milk as to transform a perfectly 
good milk into one entirely unfitted for the infant's powers of digestion. 
Thus, too frequent nursing lessens the water and increases the total solids 
in human milk, making it resemble in a certain way condensed milk; 
while too prolonged intervals result in such a decrease of the total solids 
as to render an otherwise good milk too watery and unfit for purposes 
of nutrition, however well it may be digested. The lesson that may be 
drawn from these facts is that some general rules for the feeding intervals 
should not only be recommended but enforced. The mother should 
neither injure her infant's digestion by nursing it too frequently, and thus 
giving it a too concentrated fluid, nor, by neglecting to feed it often enough, 
interfere with its nutrition by giving it a food that is too diluted. 

Regimen of Lactation. Diet. — The diet of the nursing mother should 
not essentially differ from what would be considered to be a healthy one 
for her at any time. There is no special diet which, under all circum- 
stances, is best for all nursing women during the period of their lacta- 
tion. In the early days of the puerperium there is, as a rule, more 
danger of overfeeding than of underfeeding the mother. The tendency 
is to give too much meat and solid food, with the result that when the 



FEEDING. 137 

secretion of the milk is being established the total solids are increased 
to a degree beyond the capacity of the still undeveloped digestive function 
of the infant. Infants in the early days and weeks of life thrive better 
on a milk that shows a high percentage of water in proportion to that of 
the total solids. A rule which has in my experience become almost an 
axiom is that the age of the individual infant is in inverse proportion to 
its powers of absorbing solid food, and in direct proportion to the need 
of a large amount of water in its food. A light and plentiful diet should 
therefore be given to the mother while she is confined to her bed. This 
diet should consist of milk, gruels, soups, vegetables, bread and butter, 
and after the first week a small amount of meat once during the twenty- 
four hours. When the mother is able to go out of the house again, and 
has resumed her usual habits, the quality of the diet can be very much 
increased, and she can have the usual variety of food represented by 
meats, vegetables, milk, fruits, and cereals. There are no special kinds 
of food which are contra-indicated, provided we keep the food Avithin 
the limits of the ordinary articles which commonly represent a plain but 
nutritious diet. It is very important for the nursing mother to have her 
meals at regular intervals, and during the early part of the lactation to 
take food somewhat more frequently than when she is not nursing. The 
additional meals, as a rule, should be made up of milk or cocoa. There 
does not seem to be any advantage in adding any special beverages, such 
as beer, malt, or stimulants, to her diet. She should receive as much milk 
as is compatible with her digestion, and should drink a plentiful supply 
before retiring at night. This wide range of food for the nursing mother 
has been recommended with a purpose. The food of the nursing woman 
is without doubt closely connected with that which she provides for her 
infant. Various substances are eliminated by the mammary gland, and we 
should therefore impress upon mothers the importance of a carefully 
arranged diet when they are nursing. Certain vegetables, and sometimes 
fish, will in individual cases affect the milk and cause discomfort to the 
infant. We must, then, in every case, seek to determine which article of 
diet may cause disturbance in the special woman's milk secretion, and 
eliminate that article. We should, however, be very careful not to prohibit 
this special article of diet from the regimen of a large number of Avomen to 
whom it might be of benefit rather than of harm, simply because it has 
affected the milk of a feAv Avomen. For the average Avoman a plain mixed 
diet, Avith a moderate excess of fluids and proteids over what she is nor- 
mally accustomed to, will, as a rule, give the best results. 

Exercise. — Exercise has so constant an influence on the changes Avhich 
take place in the daily secretion of the milk, that the mother should be 
encouraged to be out of bed and to Avalk about her room as soon after 
her confinement as is possible Avithout injuring her physical condition. 
Exercise is so important for promoting the proper elaboration and equi- 
librium of the milk secretion during the entire period of lactation, that it 



138 PEDIATRICS. 

should always be insisted upon, and regular hours for walking should be 
as definitely arranged during the day as the hours for eating. The exer- 
cise must, however, be in accordance with the strength of the special, 
woman, for fatigue has the same deleterious influence on the production 
of the milk as has lack of exercise. 

DISTURBED LACTATION. — The disturbances which are liable to 
occur in the course of lactation are frequent and varied. They should be 
studied carefully and recognized at once when they occur, or the continu- 
ation of the lactation may not only be interfered with but be prevented 
entirely. When colostrum corpuscles are found after the first two weeks 
of life the milk should be looked upon with distrust, and special efforts 
should be made to discover the reason of their persistence, and to prevent 
the dangers which are liable under these circumstances to arise. These 
dangers may be not only from combinations of the milk elements which 
are incompatible with the infant's digestion, but also from the disturbances 
which may arise from the free mammary elimination of foreign material. 

Drugs. — We know that during periods of mammary disturbance there 
is a much greater possibility, than when the gland is in a normal condition, 
of the direct transudation from the blood of such inorganic substances as 
arsenic, antimony, lead, iodide of potash, mercury, and others, taken by the 
mother. Well-authenticated cases come to our notice from time to time 
in which injury has been done to the nursing infant in this way, and in 
which even death has occurred from the elimination by the breast-milk 
of certain organic substances, such as colchicum and morphine. 

The greatest variety of substances have been found in the milk, but no 
definite rule as to the amount of this elimination has yet been established, 
so that our knowledge of the existence of this process is valuable as a 
prophylactic against harm, rather than as a means of direct benefit to the 
infant in disease. 

We must also recognize the clinical fact that this elimination may occur 
at any time during the nursing period in the breasts of women who, so far 
as we can ascertain, are in a perfectly healthy condition. Thus, every 
practitioner has at times doubtless observed the laxative effect on the infant 
of such drugs as compound liquorice powder given to the mother ; and a 
case has lately come to my notice where an infant vomited for weeks while 
taking the milk from the breast of its mother, who was unusually well 
and strong, but who was in the habit of drinking a considerable quantity 
of porter daily. After the porter was omitted the vomiting ceased at once, 
and did not return. 

These facts warn us that the use of drugs during the period of lactation 
should be far more limited than at other times, and that the medicinal 
treatment of disease in infants is exceedingly inexact. Saline cathartics 
may not only act unfavorably on the infant through the mammary excre- 
tion, but may lessen very decidedly the flow of the milk, and even stop it 
altogether. 



FEEDING. 139 

Menstruation. — In deciding whether a return of the menstrual period 
necessarily contra-indicates the continuation of nursing we cannot adopt 
and follow an inflexible rule, but must be guided by what seems best for 
the individual case. Infants are at times affected so seriously by the alter- 
ation in the constituents of the milk which occurs once in four weeks that 
their nutrition is markedly interfered with, and a change to a more stable 
food is indicated. Again, the only disturbance which may arise is a tem- 
porary and slight digestive attack for a day or two, which apparently does 
not materially affect the infant, and makes us hesitate to run the risk of 
depriving it of a food on which it thrives during twenty-six days out of 
twenty-eight. It is better not to be too hasty in concluding from the bad 
symptoms in the infant that we should at once withdraw it permanently 
from the breast, for the catamenia may appear once, and then not again 
for a number of months, the infant's powers of digestion in the mean 
time becoming so much more fully developed that they are unaffected by 
the milk of the catamenial period. Even when the catamenia recur regu- 
larly, the disturbance which may have been great at one period may for 
many reasons fail to recur at the next ; so that the question is reduced to 
whether the composition of the milk shows a recovery of the equilibrium 
of its constituents within a few days, or remains affected to such a degree 
as to endanger the integrity of the infant's nutrition. 

My own experience is in favor of allowing the infant to continue with 
the breast, unless it is decidedly contra-indicated by circumstances such 
as have just been mentioned. I have seldom met cases which could not 
without permanent injury be tided over the small amount of temporary 
digestive disturbance which may arise. There have, as yet, been too few 
analyses made during the catamenial period to justify us in drawing any 
definite conclusions as to the chemical status of the question ; but the 
probability is that the milk will be found to be deficient in fat and to have 
its proteids increased, following the general rule of disturbed mammary 
secretion, and that consequently it is in a condition to interfere temporarily 
with both digestion and nutrition. 

Pregnancy. — A much more serious question arises when the nursing 
mother becomes pregnant ; for here the almost universal clinical experi- 
ence is that the infant, for various reasons, cannot continue to be fed by 
its mother, it being unusual for a woman to have sufficient vitality to 
nourish properly her living child and growing foetus. The danger of reflex 
miscarriage from the continual irritation of the mammary gland by nursing 
I personally have had no experience with, but this is mentioned as one 
of the dangers contra-indicating the continuation of nursing by a pregnant 
woman. We must, however, here also not judge hastily, but take all the 
circumstances of the case into consideration before deciding on a measure 
of such vital importance to both child and foetus. If the mother remains 
strong and vigorous, and the analysis of her milk shows no deterioration, 
while the infant is a delicate one just beginning to thrive on its rightful 



140 PEDIATRICS. 

supply of natural food, or if it is during a hot period of the year, and 
especially when a wet-nurse or feeding from a milk-laboratory cannot 
be employed, it will often be wiser to take some risk and continue the 
nursing for a certain time, perhaps six or eight weeks, and then, according 
to circumstances, gradually to substitute another food. Almost every 
case will differ in the questions to be decided, and must be judged on its 
own indications and contra-indications, always, however, recognizing the 
accepted rule that lactation and pregnancy are usually incompatible. 

Management of Disturbed Lactation. — The nursing mother is inclined 
to believe that if she feels well and strong her milk must be good for her 
infant under all circumstances. She therefore frequently transgresses the 
rules which are necessary for keeping her milk in equilibrium, and she 
should be made to understand that sometimes abnormal variations are 
liable to arise, however good her general health may be. She is simply 
fulfilling a task demanded by nature from those who bear children, and her 
duty, when once she has undertaken to nurse, is to prevent as much as 
possible these variations by regulating her life to a normal standard and 
avoiding excitement. Both of these requisites of a normal lactation come- 
within the province of the physician to explain as he would any other 
branch of rational medicine. He should impress upon her that emotional 
mothers do not make good nurses, and that the physiological influence 
of the emotions on the nervous system, with its resulting changes in the 
mammary secretion, has necessarily a much wider range in women who 
are subjected to the customs and vicissitudes of modern life than it has in 
those who live in a more natural way. 

The following table shows the percentages and combinations which 
are likely to occur in abnormal milk : 

TABLE 30. 

Showing typical analyses of a, normal, a poor, an over-rich, and a bad human breast-milk. 



Pat 




Normal Milk. 

(Healthy life 

as to exercise 

and food.) 

4 


Poor Milk. 
(Starvation.) 

1.10 
4.00 
2.50 
0.09 


Over-rich Milk. 
(Rich feeding ; 
lack of exer- 
cise.) 

5.10 

7.50 

3.50 

0.20 


Bad Milk. 
( Pregnancy. 
Disease, etc.) 

0.80 


Sugar . . 
Proteids 
Mineral 


matter 


7 

1.50 
0.15 


5.00 
4.50 
0.09 




ids , 






Total sol 


12.65 


7.69 
92.31 


16.30 

83.70 


10.39 


"Water . 




87.35 


89.61 



100.00 100.00 100.00 100.00 

The terms poor and bad milk are merely relative, and in common use 
do not have a definite meaning. I have adopted the terms for the pur- 
pose of simplicity and to distinguish a milk which can be restored easily to 
a normal condition from one in which the difficulty of such restoration is 
very great. By a poor milk I mean one which represents a condition of 
lack of nourishment or starvation in the mother, but one which can easily 



FEEDING. 141 

be changed by the proper feeding of the mother. In this case the normal 
mechanism of the mammary gland has not been interfered with. By a 
bad milk I mean one which represents a profound disturbance of the 
mechanism of the mammary gland produced by many causes, disease, 
pregnancy, and especially extreme nervous conditions in the mother, and 
one which cannot be easily changed to a good milk. 

The following are some of the rules which will be found of use in 
managing a case of disturbed lactation : 

General Principles for Guidance in managing a Disturbed Lactation. 

To increase the total quantity Increase proportionately the liquids in the 

mother's diet, and encourage her to "believe 
that she will he enabled to nurse her infant. 

To decrease the total quantity Decrease proportionately the liquids in the 

( Rarely necessary. ) mother's diet. 

To increase the total solids Shorten the nursing intervals ; decrease the 

exercise ; decrease the proportion of liquids 
in the mother's diet. 

To decrease the total solids Prolong the nursing intervals ; increase the 

• exercise ; increase the proportion of liquids 

in the mother's diet. 

To increase the fat Increase the proportion of meat in the diet 

and of fats which are in a readily digestible 
and assimilable form. 

To decrease the fat Decrease the proportion of meat in the diet. 

To increase the proteids Decrease the exercise. 

(Very rarely indicated.) 

To decrease the proteids Increase the exercise up to the limit of fatigue 

for the individual. 

In attempting to formulate rules we must understand that we are 
dealing with a subject of which very little is known definitely. I can, 
therefore, at present only state my experience in a large number of cases, 
and give some general idea of how we can recognize whether we are deal- 
ing with a bad or poor milk rather than with a normal variation of a good 
milk. This knowledge of the variations which take place in human milk 
is of the utmost clinical importance during the period of lactation, for it is 
the only means by which we can decide definitely and intelligently many 
vital questions in this period. 

Instances have continually been brought to my notice where infants 
have been allowed either to continue with their mother's milk when they 
were not thriving on it, simply because it was mother's milk, or, on the 
other hand, have been weaned from their mothers for what would evi- 
dently have been insufficient reasons had the case been thoroughly under- 
stood. In both instances a proper knowledge of what can be done with 
human milk — that is. with the management of its different constituents by 
increasing or decreasing their relative proportions — would have been of 
benefit to both mother and child, and in some cases would have saved the 
life of the latter. This lack of knowledge, or rather lack of adaptation of 



142 PEDIATRICS. 

the knowledge which we possess of this branch of medicine is, to say the 
least, reprehensible, and in other branches of our art, which are more' intel- 
ligently and carefully studied, would be deemed inexcusable. Physicians 
are continually stating to their patients that human breast-milk is the best 
food for infants, and at the same time are content to ignore the very 
principles which would make their statements true. We should under- 
stand that when we speak of the superiority of breast-milk as a food, we 
mean good average breast-milk and for the average infant. 

In all these cases of disturbed lactation we must determine whether 
the symptoms in the infant are really caused by a disturbance of the milk- 
supply. We ascertain first whether the supply of milk is sufficient in 
quantity by the methods already described. We then investigate the 
quality of the milk. A chemical analysis shows us whether the percent- 
ages of the different elements are (1) normal or (2) abnormal. If we 
find them to be normal, we know that it is not the milk which is disturb- 
ing the infant, and we must seek for the cause of the disturbance in other 
sources beyond the breast. If we find the percentages to differ decidedly 
from those of average human milk, we must determine whether it is the va- 
riation from the normal average percentages or combinations of percentages 
which is producing the trouble, or whether these percentages are really well 
adapted to the infant and the cause of the trouble is to be looked for else- 
where. This can be done only by changing the different percentages and 
their combinations and watching the result. If we find them abnormal, 
we can usually determine whether it is one or several of the elements 
which are producing unfavorable symptoms, and we should endeavor by 
our treatment to change the percentages of these elements so as to cor- 
respond first to the normal average percentages, and then, if this is not 
sufficient, to reduce them to lower percentages than the average until the 
infant's digestive functions have recovered their equilibrium. We must 
not forget in applying these principles that the cause of the disturbance of 
the milk may exist in some abnormal condition of the mother, whether 
physiological or pathological, and that this cause must first be removed or 
we shall fail to regulate the milk. 

A sedentary life, with abundance of rich, mixed food, provided the 
woman has a strong, healthy digestion, appears to increase the total solids 
and to decrease the water. This increase is almost always in the fats 
and proteids rather than in the sugar and mineral matter ; in fact, the 
marked variations in human milk are almost always shown in the fat and 
proteids, and hence our attention must almost invariably be directed to> 
correcting these elements. This is fortunate, as we know of no special 
treatment, except on very general principles, by which we can alter the pro- 
portion of sugar or salts to the other constituents. A meat, or rather a 
nitrogenous, diet and fat in an easily digestible and assimilable form in- 
crease the fat in breast-milk. The proteids are more difficult to deal with. 
They have a tendency to increase in very bad and in very rich milk. The 



FEEDING. 



143 



problem which we have to solve is almost always how to decrease them, 
no matter what the milk is. Our knowledge, unfortunately, concerning 
a sure means of reducing the proteicls is very limited. Practically, how- 
ever, I have found that when the woman is in good health it is physical 
exercise which we must insist upon, preferably walking in the open air 
and within the limits of fatigue. A walk of from one to two miles twice 
daily I have found to be about what the average healthy woman in New 
England needs to reduce the percentage of the proteids in her milk ; but 
the amount of exercise must be carefully regulated according to the 
physical capabilities of the individual. 

Bearing in mind these simple rules, and having determined, by means 
of an analysis or analyses, the cause of the special disturbance, it is often 
possible to regulate the nursing period in cases in which a lack of this 
knowledge would necessitate weaning. In this way also serious harm to 
the infant may be avoided. 

The following tables represent the changes which took place in the 
milk in certain cases of disturbed lactation. 



TABLE 31. 

[Human Milk. ) 
Showing the influence of a luxurious life on a poorly fed but healthy wet-nurse. 



Fat , .... 

Sugar 

Proteids 

Mineral matter 

Total solids 

Water .......... 



I. 




II. 


III. 




IV. 


Normal. 


Two days before 
change of food. 


Rich food and but 
little exercise for 
a month. 


Food and 
regula- 


4.00 




0.72 


5.44 




5.50 


7.00 




6.75 


6.25 




6.60 


1.50 




2.53 


4.61 




2.90 


0.15 




0.22 


0.20 
16.50 




0.14 


12.65 


10.22 


15.14 


87.35 




89.78 


83.50 




84.86 



100.00 



100.00 



100.00 



TABLE 32 

[Human Milk) 

Showing a bad milk and one whicJi it was impossible to manage on account of the continued 
recurrence of the same cause, uncontrolled emotions. 



Fat 

Sugar 

Proteids 

Mineral matter 

Total solids 12.65 

Water c 87.85 

100.00 





Emotions causing dis- 


formal. 


turbance in infants 




digestion. 


4.00 


0.62 


7.00 


5.80 


1.50 


4.21 


0.15 


0.20 



10.83 
89.17 

100.00 



144 



PEDIATRICS. 



TABLE 33. 

[Human Milk.) 

Showing a milk possible to manage, because the mother, though excitable, was able and willing 

to control her emotions. 



Normal. 

Fat 4.00 

Sugar 7.00 

Proteids 1.50 

Mineral matter 0.15 

Total solids 12.65 

Water 87.35 

100.00 



Infant doing badly. 
Colic. Mother 
before treatment. 

1 62 
6.10 
3.54 
0.17 



11.43 

88.57 

100.00 



Infant doing well. 



Mother 
treatment. 

3.20 
6.40 
2.52 
0.18 



after 



12.30 

87.70 

100.00 



Wet-nurse pro- 
vided but not 
used 

3.04 
6.60 
2.32 
0.12 



12.08 
87.92 

100.00 



In the above case the mother was very nervous and wished to nurse 
her infant, but thought that she could not, as she had been discouraged 
by her nurse and physician. She was then told that she could nurse in a 
week, if in the mean time she took proper food and exercise and withdrew 
the infant from the breast. This she did, and had her breasts regularly 
pumped, with good results. 

TABLE 34. 

[Human Milk. ) 

Showing the effect of the catamenia on human milk. 

Normal Catamenia, Seven Days after Forty Days after 

Second Day. Catamenia. Catamenia. 

Fat 4.00 1.37 2.02 2.74 

Sugar 7.00 6.10 6.55 6.35 

Proteids 1.50 2.78 2.12 0.98 

Mineral matter. . . 0.15 0.15 0.15 0.14 

Total solids 12.65 10.40 10.84 10.21 

Water 87.35 89.60 89.16 89.79 

100.00 100.00 100.00 100.00 



TABLE 35. 

[Human Milk. ) 

Showing a milk in which the proteids, which were disturbing the infant, could not be reduced 
until the mother was m.ade to walk comfortably, and thus without fatigue. 



Normal. 



Fat 4.00 

Sugar 7.00 

Proteids 1.50 

Mineral matter... 0.15 

Total solids 12.65 

Water 87.35 

100.00 



Infant with colic 
and vomiting. 

Mother taking 
no exercise and 
very rich food. 

3.05 
6.10 



0.16 

13.20 
86.80 

100.00 



Infant as before. 
Mother walking 
two miles daily, 
but having blis- 
ters from uncom- 
fortable shoes. 

0.65 

5.25 

3.82 

0.18 

9.90 
90.10 



Infant doing well. 
Mother walking 
two miles. Easy 
shoes, no blisters, 

3.34 
6.30 
2.61 
0.16 



100.00 



12.41 
87.59 

100.00 



FEEDING. 



145 



TABLE 36. 

(Human Milk.) 
Snowing how a milk can be managed while the nursing is continued. 







Infant two weeks 












Normal. 


old, with serious 
general nervous 
symptoms and 
pain. Mother 
eating much 


Mother walking 
and eating less 
meat. Infant 
entirely well. 


Infant four 
months old, with 
pain and diar- 
rhoea. Mother 
not walking so 


Infant doing well. 
Mother walking 
two miles daily. 
Milk diluted one- 
fifth 






meat and taking 




much. 










no exercise. 










Fat 


. 4.00 


3.44 


2.09 


3.98 




3.19 


Sugar 


.. 7.00 


5.60 


6.70 


7.00 




5.60 


Proteids. . . . 


. 1.50 


3.96 


1.38 


2.22 




1.78 


Mineral matt 


er 0.15 
.. 12.65 


0.20 


0.15 


0.19 
13.39 




0.16 


Total solids . 


13.20 


10.32 


10.73 


Water 


. 87.35 


86.80 


89.68 


86.61 




89.27 




100.00 


100.00 


100.00 


100.00 


100.00 



As is seen from the last analyses., the infant did not do well until the 
mother began to exercise, and at four months it was again affected by 
apparently the high percentage of the proteids. The infant was consid- 
erably under the weight corresponding to that of the average infant of 
four months. It was found to nurse twenty-five minutes at a time, and by 
calculation from its weight before and after nursing, it was found to take 
from 80 to 120 cc. (20 to 30 drachms). This amount being larger than 
the probable size of its stomach demanded, the time of the nursing was 
reduced to twenty minutes, and 20 cc. (5 drachms) of sterilized water 
were given in the middle of the nursing, thus changing the percentages in 
the milk to the figures which are represented in the last column. This 
calculation is on the basis of 100 cc. (25 drachms) to each nursing. 

So long as this method of feeding was adhered to, the infant did well. 
It was evidently a case in which the infant could not digest over two per 
cent, of proteids. 



TABLE 37. 

{Human Milk.) 

Showing that even for a long interval the breasts may be pumped and the result be a 

successful nursing. 



Normal. 

Eat 4.00 

Sugar 7.00 

Proteids 1.50 

Mineral matter . 0. 15 

Total solids 12.65 

Water 87.35 

ioo.ocT 



Infant showing nervous Infant showing no uric 
symptoms and much acid and thriving. 



ic acid. Mother 
king no exercise and 
uch rich food. 
5.71 


Mother walking two 
miles and not eating 
much meat. 
2.67 


4.00 






6.60 


4.29 






3.18 


0.19 






0.17 


14.19 


12,62 


85.81 






87.38 



100.00 



100.00 



10 



146 



PEDIATRICS. 



In this case the infant was withdrawn from the breast temporarily, and 
the breasts pumped for twenty-seven days. When the analysis presented 
the figures seen in the last column, the milk was treated by diluting it, as 
in the previous case, and the infant was put back to the breast. 

TABLE 38. 

[Human Milk. ) 

Showing the value of retaining the breast-milk by managing even an unpromising case. 

Infant with colic 

and failing. Infant put on 

Mother no ex- bottle. Breasts Exercise in- 

ercise, nursing pumped every creased to two Eating much 

irregularly, four hours. miles. Small meat. Exer- 

Normal. irregular and Moderate ex- amount of cise the same, 

improper ercise, — one meat, 

sweet food. mile. Full 

Nervous, wor- regular diet, 

ried condition. Tranquil. 

Fat 4.00 0.34 3.24 2.79 4.84 

Sugar 7.00 5.40 5.45 5.05 6.00 

Proteids 1.50 3.61 3.95 3.66 3.42 

Mineral matter... 0.15 0.18 0.16 0.20 0.17 

Total solids 12.65 9.53 12.80 11.70 14.43 

Water 87.35 90.47 87.20 88.30 85.57 

100.00 100.00 100.00 100.00 100.00 

The last case represents a bad milk from the failure of the healthy 
mother to conform to the rules of lactation. This bad milk, represented 
in the second column, had to be made into a rich milk by regular feeding 
before any attempt could be made to alter the ratio of the constituents. 
The proteids were then reduced somewhat by exercise, and, after the 
breasts had been pumped for two weeks, the analysis showed the percent- 
ages as represented in the last column. The milk was then diluted with 
sterilized water, and the infant was put to the breast and did well ; in fact, 
was carried through an attack of retro-pharyngeal abscess with this breast- 
milk. 

The decrease in the total quantity of the milk is of ordinary occurrence 
at any time during lactation, but it is most common among civilized races 
at about the eighth to the tenth month. When it occurs early in the lac- 
tation it is very disheartening to the mother if she is desirous of continuing 
her nursing. She becomes fearful that the flow of milk may stop alto- 
gether, and the nervous influence thus brought to bear on the mammary 
gland tends to increase the disturbance. We should therefore encourage 
her to believe that the milk will return. The following case illustrates 
what has just been said : 

The mother was much discouraged because her milk lessened in quantity early 
in the lactation, and she was convinced that it would not return. She had been 
taking, without my knowledge, a disproportionately small amount of fluid in her diet. 
There was an element in this case which the intelligent nurse brought to my notice, — 
namely, that the infant was not vigorous, and when put to the breast sucked feebly 
and called upon the gland for very little milk. Reacting to this lack of stimulus, the 



FEEDING. 147 

gland, although in a normal condition, secreted only the small amount demanded by 
the infant, and the milk lessened day by day. Treatment was instituted on the sup- 
position that the mammary gland is practically self-regulating as to the amount of 
food which it will elaborate at a given nursing. If it happens to be called upon to 
nourish twins, it will increase the amount of its supply. If the infant which is put 
to it has a small gastric capacity, it will produce the amount needed for that capacity. 
I assured the mother that the milk would return, and I treated directly the mammary 
gland itself. An increase was made in the amount of liquid in the mother's diet, and 
the breasts were, after each nursing, pumped gently, skilfully, and thoroughly. The 
breast-pump supplemented the feeble action of the infant, and when more work was 
required of the gland it began to produce more milk. The increase in the liquid diet 
supplied the gland with materials to work with, and its mechanism ceased to be dis- 
turbed by the nervous influence emanating from the mother. She became cheerful 
when she found the milk returning, while the infant, now that the milk could be 
procured more easily, demanded more, sucked more vigorously, and thus satisfied the 
sensitive mechanism of the mammae. 

The next case points to the possibility of our being at times too hasty 
in the decision to deprive an infant of its mother's milk. 

The mother, a rather delicate primipara, twenty-five years of age, was delivered 
of a boy seven pounds in weight. Within four hours puerperal convulsions set in, 
from which she recovered, but was left with albuminuria 0.25 per cent, and casts. 
The latter disappeared in a few days, but the albumin, although somewhat dimin- 
ished, continued ; and the patient, naturally of a calm disposition, was in a highly 
nervous condition, fearing that she could not nurse her infant, but decidedly opposed 
to having a wet-nurse. The milk appeared in considerable quantity on the fifth day, 
but the infant did not thrive, and, although it gained somewhat in weight, was very 
fretful, slept very little, and looked ill, so that the attending physician became 
alarmed, and after treating it for its dyspepsia without much success until it was five 
weeks old, and finding that there was still about 0.25 per cent, of albumin in the 
mother's urine, decided with me that the breast-milk should be withheld until we 
could determine the cause of the trouble, and an analysis was accordingly made, with 
the following result : 

Fat 1.62 

Sugar 6.10 

Proteids 3. 54 

Mineral matter 0. 17 

Total solids 11.43 

Water 88.57 

100.00 

This analysis suggesting the probability that the large amount of proteids was 
Causing the disturbance of digestion, and that the small amount of fat was not suffi- 
cient for nutrition, the attending physician was very anxious to procure a wet-nurse ; 
but while we were endeavoring to get a proper one, we decided to empty the mother's 
breasts with the breast-pump every day, thus relieving her from the worry of attempt- 
ing to nurse her infant and seeing it fail to gain. She also obtained in this way un- 
disturbed nights and a great deal of out-door life. The infant was in the mean time 
placed on a substitute food, which was digested very well, and, as it ceased to cry, 
the mother's mind became tranquil, and the albumin in her urine in a few days was 
reduced to a trace. The treatment was carried out for a week, the milk continuing 



148 PEDIATRICS. 

to flow freely, and an analysis (I.) was then made of the mother's milk and also of 
that of a healthy wet-nurse (II.) whose infant was thriving on its mother's milk. 

I. II. 

Mother. Wet-Nurse. 

Fat 3.20 3.04 

Sugar 6.40 6.60 

Proteids 2.52 2.32 

Mineral matter 0.18 0. 12 

Total solids 12.30 12.08 

Water 87.70 87.92 

100.00 100.00 

The two milks being equally good, it was decided to allow the infant to begin to 
take one nursing daily from its mother, although the proteids were still about one per 
cent, higher than the infant seemed likely to digest ; it was given to its mother, nursed 
well, seemed satisfied, digested its meal without trouble, and at six months was still 
being nursed and was thriving. 

The next case illustrates the principle that too frequent nursing lessens 
the water and increases the total solids in human milk, making it re- 
semble in a certain way condensed milk. It also illustrates what has 
been stated concerning the two important questions to be considered in 
the management of a normal lactation, — namely, that the digestion as well 
as the nutrition must be regarded. This case is one of the numerous in- 
stances of the same kind which have come to my notice, and also empha- 
sizes the fact that infants are often weaned from the breast when there is 
not the slightest necessity for it. 

The mother, a healthy primipara about twenty-two years old, had nursed her 
infant for six weeks, during which time the infant was fretful, suffered much from 
colic, and never seemed satisfied. There was, however, a continual gain in weight, 
although the faecal discharges showed evidence of the food not being properly digested 
and were numerous and watery. By advice of the attending physician, the infant 
was weaned. The mother came to me for advice in regard to placing her infant on a 
substitute food. On inquiry I found that this infant had been nursed almost continu- 
ously night and day, with intervals usually of only one hour, and it was evident that 
the frequent nursings had resulted in producing a concentrated milk which the in- 
fant's gastro-enteric tract was rebelling against and was not digesting, although suffi- 
cient food was being absorbed to prevent up to this time any interference with the 
general nutrition. This infant, then six weeks of age, was deprived of its supply of 
good human milk in the middle of the summer simply because the important matter 
of changing the intervals had not been thought of as a means of improving the milk 
and relieving the pain and apparent hunger. There seems to be no doubt that if the 
milk in this case had been properly managed it would have agreed perfectly with the 
infant. I would also add in connection with this case that when the digestion is not 
carried on properly the nutrition must soon suffer, and it is only in the early weeks 
of a disturbed digestion that, as a rule, we find the nutrition to be unimpaired. 

The next case is one of a multipara who was under my care at the City Hospital, 
and who up to the time of her entrance had been nursing her infant, which was 
thriving. The patient stated that her milk had always been abundant and of good 
color up to the time when she was separated from her infant, which was twelve hours 



FEEDING. 149 

previously, as she had to be away from home for that time. At the end of twelve 
hours the breast was found to be so distended that the breast-pump had to be applied. 
The milk was drawn with great ease, almost flowing of itself, and in considerable 
quantity, but it no longer resembled the milk of the previous nursings which had been 
at the proper intervals. On the contrary, it was clear, with very little color, the total 
solids were reduced to a minimum, and it no longer would have nourished the infant. 
The treatment of this case was of course to pump the breasts every three hours 
until the infant could again be nursed. 

As an illustration of the harm which may come to an infant from the 
percentage of fat in its mother's milk being too high, and also of the 
means to employ either to increase or to decrease the fat in breast-milk, 
this case will be of interest. 

The mother was a healthy primipara. She had plenty of milk, but the infant 
suffered from colic and had very frequent watery dejections. She was eating a great 
deal of meat three times daily and not taking much exercise, so it was naturally sup- 
posed from the symptoms of the infant and the diet of the mother that an over- 
percentage of fat was one of the elements which were disturbing the lactation, and 
that a high percentage of proteids would also be found. The analysis proved this 
supposition to be correct : 

Primipara. Healthy ; eating much meat ; not taking much exercise. 

Tat 4.96 

Sugar 6.60 

Proteids 3.29 

Mineral matter 0. 17 

It was therefore decided to reduce the meat to a minimum, which was done, and 
three days later an analysis gave the following figures : 

Eating little meat. 

Fat 1.73 

Sugar 5. 70 

Proteids 3.74 

Mineral matter 0.13 

The milk was found to be lessening in quantity. The infant's dejections were less 
numerous and had more consistency ; but it was not gaining, and continued to have pain. 
In fact, the analysis showed a poor milk, or even a bad one, as represented by the usual 
combination of a low percentage of fat and a high percentage of proteids. The woman 
was consequently made to eat a moderate amount of meat, and to exercise more, and 
three or four days later the analysis showed an improvement in the fat : 

Eating moderate amount of meat ; taking more exercise. 

Pat 2.42 

Sugar 5. 50 

Proteids , 3. 55 

Mineral matter 0.15 

The infant now began to gain in weight, but continued to have colic, as was expected 
from the high percentage of proteids. The exercise was still further increased, and a 
later analysis showed a decided lessening of the proteids. 



150 PEDIATRICS. 

Exercise still further increased. 

Fat 2.35 

Sugar 6.25 

Proteids 2.69 

Mineral matter 0.15 

The infant then began to have regular movements, of good consistency, and no 
longer had pain j it also gained regularly in weight, and looked well and strong. The 
mother regulated her diet, exercise, and sleep in accordance with the requirements of 
her infant, and her milk again became abundant. 

We shall, of course, often fail in our attempts to manage the percent- 
age of fat in this way, but this case illustrates exactly the changes which 
it is usually necessary to produce in order to alter a high fat percentage. 
The proteids also being high, there was an over-rich milk to deal with ; 
taking away the fat-producing element reduced the fat to a low percentage ; 
exercise reduced the high percentage of proteids, and a combination of 
sufficient meat and exercise finally produced a milk which could be di- 
gested. 

This next case illustrates a number of points in the management of 
lactation. A high percentage of the proteids was creating the disturbance 
in the infant, and it was their final reduction through treatment that per- 
mitted the lactation to go on. 

The mother, a remarkably healthy and vigorous multipara, living in the country, 
had a plentiful supply of milk. Her diet consisted mostly of vegetables, and she did not 
take much exercise. The infant was not thriving, having had continued attacks of colic, 
with frequent vomiting, and it did not gain in weight. The analysis showed a bad milk, 
which was contrary to what we should usually expect to find in the milk of a mother 
who was in such perfect health as this one was. 

Pat 0.52 

Sugar 6.80 

Proteids 2.48 

Mineral matter 0.15 

Total solids 9.95 

Water 90.05 

100.00 

The mother was instructed to eat meat and walk two miles every day. One month 
later, as the infant had not improved, another analysis was made, which showed that the 
milk was in a worse rather than a better condition. 

Pat 0.45 

Sugar 6.15 

Proteids 2.47 

Mineral matter 0. 16 

Total solids 9.23 

Water 90. 77 

TooToo 

It was found that the mother had eaten meat but once a day, and in small quantity j 
also that she had not walked much. I then insisted on her eating meat three times a 



FEEDING. 151 

day, and walking three miles. This she did for two weeks, when the infant was found 
to have gained slightly in weight, but to still have colic and vomiting. Another analy- 
sis showed an increase in the fat. 

Fat 1. 53 

Sugar 6.68 

Proteids 2. 48 

Mineral matter 0. 16 



Total solids 10.85 

Water 89.15 

100.00 

During the next two months the walking was continued, and the meat increased in 
quantity. The infant continued to vomit and to have colic until the mother was made 
to ride on horseback every day, when the pain ceased, and from that time the infant 
gained steadily in weight, and was well and strong during the rest of the lactation. An 
analysis made two and one-half months after this procedure showed that at last the pro- 
teids had been reduced to come within the limits of the infant's digestion, and that the 
fat, although still having a low percentage, had been increased sufficiently for the infant's 
nutrition. Thus a bad milk was finally changed to a good one. This infant evidently 
could not digest a percentage of proteids approaching 2, but fortunately could be nour- 
ished on a low percentage of fat. 

Fat -. 2.01 

Sugar 6.90 

Proteids 1.54 

Mineral matter 0. 17 

Total solids 10.62 

Water 89.38 

100.00 

The next case was that of a poor milk. 

The infant was four months old. It was perfectly well and was digesting well, but 
had not gained for three weeks. The mother was producing from her breasts a suffi- 
cient quantity of milk, but the analysis showed that this milk had to be modified within 
the breast by a regulation of the diet of the mother : 

Fat 1.29 

Sugar 6.05 

Proteids 2.93 

Mineral matter 0. 12 

Total solids 10.39 

Water 89.61 

100.00 

She was consequently made to eat an increased amount of meat, and in the course 
of a few weeks the infant was thriving and gaining in weight. 

The next case was that of a wet-nurse whose infant was digesting well, 
gaining in weight, and happened to be of about the same age as that of 
the infant whom she was hired to nurse. In order to see if this nurse's 
milk would agree with the foster-infant, the nurse and her infant were 
brought to the house of the foster-child, and were comfortably lodged and 
plentifully fed. 



152 PEDIATRICS. 

Twenty-four hours later both infants began to have colic and green faecal discharges* 
An analysis of the milk showed a high percentage of proteids : 

Fat ... 3.19 

Sugar 6.40 

Proteids 3.11 

Mineral matter „ 0. 15 

Total solids 12.85 

Water 87.15 

100.00 

The nurse was then given a lighter diet with a greater proportion of liquids, and was 
made to walk one mile twice daily. By weighing the infants just before and just after 
a nursing, it was found that they took from 90 £c 120 c.c. (3 to 4 ounces) in fifteen min- 
utes. The infants were then allowed to nurse for ten minutes. 30 c.c. (1 ounce) of 
sterilized water was next given to them, and they were then allowed to nurse for ten 
minutes longer. In this way it was estimated that they were receiving in their stomachs 
120 c.c. (4 ounces) of food in which the percentage of the proteids was under 2.5. The 
infants ceased to have colic, and the faecal discharges became normal. The nurse's 
infant was then sent away. Two weeks later the foster-infant was thriving, and, as 
another analysis of the milk showed a sufficient reduction of proteids, the sterilized water 
was omitted. 

Fat . 2.87 

Sugar . . . 6.25 

Proteids 2.90 

Mineral matter 0. 15 

Total solids . . 12. 17 

Water 87.83 

100.00 
During the rest of lactation the infant digested well and gained fairly in weight. 

The following case was that of a perfectly healthy primipara, whose 
infant digested her milk well and gained in weight. 

The case shows how at times an infant can thrive on what appears to be too high 
percentage of some of the solids in the milk. The analysis of her milk was as follows : 

Fat 4.11 

Sugar 5.90 

Proteids 3.71 

Mineral matter. .'. . 0.21 

Total solids . . . . 13.93 

Water 86.07 

100.00 

In contrast to this case was the following one in which the infant was 
evidently thriving. 

The mother was delicate and frail, and the infant was fed by a healthy-looking 
wet-nurse. In the early part of the lactation the infant did not thrive, and, as the 
mother was so delicate, it was not deemed advisable to attempt to improve the quality 



Fig. 44. 




Colostrum milk from cow. (Photo-micrograph.) 



Pig. 45. 




Colostrum milk from woman. (Photo-micrograph.) 



FEEDING. 15H 

of her milk. The interesting point in connection with this case is the inability of the 
infant to digest a poor milk and its ability to digest perfectly well the wet-nurse's milk, 
which in its analysis showed a very high percentage of fats and of proteids and a low per- 
centage of sugar : 

Tat 4.72 

Sugar 4.55 

Proteids 4. 74 

Mineral matter (X 19 

Total solids 14.20 

Water 85.80 

100.00 

In the following case it was found impossible to change the percentages 
of the elements in the milk. 

The woman had a moderate quantity of milk, and nursed her infant for two or 
three months. The infant did not gain, it had colic, and at times vomited. The 
analysis showed that it was in the class which I have designated as "bad :" 

Fat 1.61 

Sugar 4. 67 

Proteids 4.07 

Mineral matter ....... 0.17 

Total solids 10. 52 

Water , 89.48 

100.00 

An increase of meat in this mother's diet and more exercise had no effect on the 
percentages of the elements of her milk, and the infant was therefore weaned. Soon 
after beginning to take a substitute food from the milk-laboratory the infant ceased to 
have colic and gained in weight. The percentages of the elements in the substitute food 
which produced such an immediate change in the infant's condition were as represented 
in this prescription : 

Fat 3.50 

Sugar 7.00 

Proteids . , 1.00 

It was merely necessary to raise the percentages of the fat and sugar, and reduce 
that of the proteids, in order to produce this rapid and satisfactory result. 

The next analysis is that of a woman's milk, which is instructive for 
a number of reasons : 

Fat 2.30 

Sugar 6. 65 

Proteids 2. 57 

Mineral matter 0. 12 



Total solids 11.64 

Water , 88.36 

100.00 

The percentage of fat is low, and that of the proteids is rather high. The infant, 
with the exception of being somewhat constipated, was always well, gained in weight,. 



154 PEDIATRICS. 

and showed no digestive disturbance during the lactation. This was remarkable, as 
the mother's catamenia returned regularly during the lactation from the time that the 
infant was four months old. There was considerable flowing at the time of the cata- 
menia, and the mother was habitually constipated and did not have a very good appe- 
tite. The infant did not seem to be affected by any of these conditions. The analysis 
of this milk was made from a specimen of the "middle milk," which was taken 
between the catamenial periods. 

It may be of interest, in connection with what has been said concerning the 
variations in the milk which may arise from emotional causes and menstruation, to 
report the analysis of a milk of a mother and a wet-nurse where these influences 
appeared to produce certain chemical changes. The mother, a healthy but rather 
delicate primipara, the period of whose pregnancy had been supervised by me with 
the greatest care, but whose temperament was subject to extremes of despondency 
and excitement, was delivered, after a short and easy labor, of a healthy boy. She 
was exceedingly anxious to nurse her infant, but within a few hours after its birth 
she was seized with an uncontrollable fear that she would be unable to do so. In 
spite of all the assurances to the contrary which could be given to her, and the plen- 
tiful supply of milk which in due time came in the breasts, she remained in a very 
nervous, despondent condition. As the infant began to show decided signs of indi- 
gestion, I thought it best, before proceeding further, to investigate the composition of 
the milk. The analysis resulted as follows, and plainly showed the necessity of not 
persisting further, as it was evidently much altered from unavoidable nervous con- 
ditions, which seemed likely to recur through the whole of her lactation : 

(Mother's Milk.) 

Fat o 0.62 

Sugar 5. 80 

Proteids .'. . ... f .......... . ..-. . 4.21 

Mineral matter. ..■-...... . . „ ... 0.20 

Total solids 10.83 

Water 89.17 

100.00 

Under these circumstances, a healthy wet-nurse, whose own infant was strong 
and thriving, was employed, and the foster-infant immediately began to gain in 
weight and ceased to show any digestive disturbance. After a month, however, it 
was found not to have made its weekly gain, to be unusually restless, and to be having 
frequent faecal discharges. It was then discovered that the wet-nurse was menstru- 
ating, and on the second day the following analysis of her milk was made : 

( Wet-Nurse. ) 

Pat 1.37 

Sugar 6. 10 

Proteids 2. 78 

Mineral matter 0. 15 

Total solids 10.40 

"Water 89. 60 

100.00 . 

The catamenia lasted about four days, and did not return for some months. The 
infant after the first twenty-four hours showed no disturbance whatever, soon began 
to gain, and was not affected by the subsequent, occurrence of the catamenia. An 
analysis, made one week after the catamenia had ceased, showed a decided change 
for the better ; that is, increased fat and decreased proteids. Forty days after the 



FEEDING. 155 

catamenia a still greater improvement was found in the milk, as was anticipated from 
the thriving condition of the infant. The change in the percentage is shown in 

the following analyses : 

Seven Days Forty Days 
after Ca- after Ca- 
tamenia. tamenia. 

Pat 2.02 2.74 

Sugar 6.55 6.35 

Proteids 2.12 0.98 

Mineral matter 0. 15 0.14 

Total solids 10.84 10.21 

Water 89.16 89.79 

100.00 100.00 

The following case is of considerable interest with reference to what 
has been said in regard to the incompatibility of pregnancy and lactation. 
Unfortunately, a full consideration of the condition of the milk cannot be 
presented, as it rapidly disappeared from the breast after the first analysis 
was made, and, before another specimen could be procured, had disap- 
peared entirely. 

The milk was taken from one of my patients who had been pregnant for three 
months and at the same time was nursing an infant nine months old. 

Fat 7.64 

Solids, not fat 6.04 

Total solids 13.68 

The infant at the breast was not thriving. It had been digesting its mother's 
milk perfectly and had been gaining in weight until the pregnancy had existed for some 
weeks. At the time the analysis was made the infant's digestion had evidently been 
weakened, and as a result it had ceased to thrive and was rapidly losing in weight. 

This analysis will be found to illustrate several facts. In the first place, it repre- 
sents a very rich food. The total solids are even greater than appear in most cow's 
milk, and the fat is almost double the percentage which is considered normal in both 
human and cow's milk. 

It also shows that a food may be unusually high in the percentage of its total solids 
and yet not of a character suited for the nutrition of an infant. The explanation of 
this fact is that although for a time an infant may digest fairly well a rich food, yet 
that nature has provided that the percentages of the elements in its food should remain 
within certain limits. If these limits are transgressed, either by giving too low or too 
high a percentage of any of the solids in the food, the nutrition will be interfered with. 
In the latter case the digestive function of the infant actually becomes weakened, and 
the strong food soon begins to act as a foreign body. The absorption of the food is next 
interfered with, and the infant starves as readily on the strong food which cannot be 
absorbed as on the weak food in which the needed elements are lacking. 

This analysis also represents a condition which, in the majority of cases of preg- 
nancy, occurs after the first six or eight weeks, — namely, a much disturbed mammary 
equilibrium. The percentage of fat in proportion to that of the solids not fat is so 
entirely different from the percentages of the different elements in a normal milk that 
we may say that this milk of pregnancy represents a condition of profound disturbance. 

This especial analysis must not be taken as a standard one for the milk of preg- 
nant women, for, in all probability, analyses of milk under these conditions differ very 
widely, yet invariably show an absence of the normal percentages. 



156 PEDIATRICS. 

Prolonged Lactation. — In healthy women the milk towards the end 
of a normal lactation has a tendency to return to the condition which we 
notice at the very beginning of lactation ; that is, the product of the mam- 
mary gland becomes unstable and the percentages show a poor or a bad 
milk. In rare cases I have met with women whose milk remained of fair 
quality and who could continue their nursing into the second year with- 
out apparent detriment to themselves or to their infants. There is, how- 
ever, no reason for thus continuing the lactation, even if the mother is 
healthy and the milk good, for at the end of the first year, human milk, 
whether good or bad, is not a food which is adapted to the corresponding 
stage of development of the infant's digestive organs. Unmodified cow's 
milk and starch in some form are much better adapted to the stage of de- 
velopment of the digestive organs of the second year, and should therefore 
at that time be substituted for human milk. 

Mixed Feeding. — It not infrequently happens to nursing women, when 
their general health is not in a normal condition, that the supply of milk, 
while good in quality, is not sufficient in quantity to satisfy the infant, and 
the question arises whether the mother's milk should be entirely given up, 
or whether it should be supplemented by other food. My experience is. 
in favor of assisting the mother to nurse her infant during the earlier 
months of its life. When the substitute food can be carefully regulated, 
and when the mother's milk is of good quality, this method is superior to> 
that of withdrawing the mother's milk and feeding the infant exclusively 
upon a substitute food. 

We have, on the one hand, a better opportunity for regulating the- 
mother's milk, by increasing or diminishing the number of the substitute 
feedings, and, on the other hand, if the mother's milk agrees with her 
infant, an excellent opportunity for making our substitute food correspond 
to what nature has provided. 

In arranging a mixed feeding we should in every case first have an 
analysis made of the mother's milk, and, if her milk has been agreeing 
with the infant, make the substitute food correspond to the maternal. It 
is also well to have an analysis of the mother's milk made at an early 
period of her lactation, as soon as the mammary gland has acquired its 
equilibrium and when the infant is thriving. This is a very important 
precaution, which may be of great use to us at a later period when the 
mother's milk may from many circumstances be disturbed or entirely lost- 
When such an accident happens, we know exactly what the composition 
of the milk was on which the infant was thriving, and can at once arrange- 
a proper substitute food. 

The following cases illustrate this statement : 

An infant was thriving on the milk of a healthy wet-nurse. One day, without 
giving any warning, the nurse left the house and never returned. The infant had to 
be put on a substitute food, as another nurse could not be procured. It was left in the 
middle of the hot weather without the food which had been so well adapted to its. 



FEEDING. 157 

digestion. Unfortunately, the precaution of having an analysis made of the wet- 
nurse's milk had not been taken, and it was some time before I was able to substitute 
a food which would agree with the infant. 

The second case was where the mother's milk, after careful management, had be- 
come fitted for her infant, and where the infant was thriving. One day the mother 
received a nervous shock from seeing the arm of another of her children dislocated. 
Within a few hours the milk entirely disappeared from her breasts and did not return. 
The analysis of her milk, which had been previously made, provided me with a guide 
by which I could at once have a substitute food prepared which would correspond to the 
food which the infant had been receiving from its mother. This was done, and the 
infant continued to thrive, showing no bad symptoms from the change of food. 

There are certain points to be considered in mixed feeding. First, if 
the mother's milk is agreeing with the infant, the substitute food should 
be of the same composition. Second, if the mother's milk is fully digested 
by the infant but is lacking in certain nutritive qualities, the absence of 
which prevents the infant's nutrition from being normal, we should, after 
the first week, alter the composition of the substitute food so as to make 
it fulfil the requirements of nutrition by increasing the percentage of that 
special element in the substitute which is deficient in the composition of 
the maternal milk. 

The times at which the substitute food should be given will depend 
upon the number of feedings which are found to be necessary in addition 
to the maternal feedings, and we should carry out the same principles 
in this mixed feeding that have been laid down for the general manage- 
ment of human breast-milk. If the mother's milk is lacking in quantity 
we should make the intervals between her nursings longer, and introduce 
one or two substitute feedings according as the age of the child requires 
shorter or longer intervals. If, on the contrary, the mother's milk is 
abundant, but either too strong or too weak, we should make the intervals 
of her nursing correspondingly long or short. In this way, with an accu- 
rate knowledge of the percentages which exist in the mother's milk, and 
with our power to change these percentages in substitute feeding, we can 
usually in a week or ten days regulate the substitute feeding of the infant 
to such a degree that the mother's milk will also agree with the infant, and 
the infant will thrive again. 

WEANING. — There is no doubt that in a considerable number of 
cases occurring in the practice of physicians among civilized nations the 
mother's milk appears to be entirely unfit for her offspring, and it be- 
comes a question whether the infant shall be withdrawn from its mother's 
breast temporarily or entirely. In such an emergency the careful and 
repeated analysis of the milk will enable us to determine this question 
wisely. 

I am convinced that a large number of infants are deprived of their 
natural food and weaned on insufficient grounds. We thus assist to keep 
up the resulting high mortality figures, and I believe that these figures will 
be sensibly reduced when, in consequence of our taking a more enlightened 



158 PEDIATRICS. 

view of the subject, we increase the number of infants who are fed during 
the* first three or four months of life upon a suitable breast-milk. 

A particular reason among many for waiting at least three or four 
months before weaning is presented by the fact that the stomach, after 
growing rapidly, has by the fourth or fifth month become a more perfect 
receptacle both as to size and to function. 

A number of nursing women find that at variable periods in the course 
of their lactation their milk begins to fail, and they are forced first to lessen 
the number of their nursings and then to wean entirely. The time, then, 
when the infant should be weaned almost always settles itself, without our 
intervention, at varying periods. The period of lactation, and the one 
which might be called physiologically normal, can, when the breast-milk 
remains of good quality and quantity, be carried through the first year 
with benefit. We have certain guides which aid us in determining the 
proper time for beginning to wean. Physiologically, we know that certain 
functions, such as that which converts starch into glucose, are but slightly 
developed in the early months of life, and that they are only gradually 
established during the first year, and not, as a rule, perfected and in a con- 
dition in which we can call upon them with impunity until the last two or 
three months of that year. A sign which aids us in judging the progress 
of this development of the functions is the appearance of the teeth, call- 
ing our attention to the fact that nature is preparing the infant to digest 
and assimilate a form of food different from that which it has thus far 
received by sucking. The presence of six or eight incisors corresponds 
usually in the normally developed infant to the full development of the 
pancreatic secretion. 

A most valuable index which assures us that we need not be anxious 
to change the infant's food during the first year is the continuous increase 
in its weight, which, with a general healthy condition, results from a nor- 
mal lactation. We must allow, however, for certain variations which in 
special cases are as important as is the rule to terminate the lactation at a 
definite period. The period of lactation may be curtailed or lengthened 
by a month or two according to the season of the year, the development 
of the teeth, or the condition of the child from illness or convalescence. 
Under such circumstances it may be wiser to feed the infant from the 
breast during the heated portions of the year, and to wean it in cool 
weather, before or after the hot season, according to the individual case. 
An interdental period is also preferable to a dental period, on account of 
the possible disturbances which may arise in the latter and interfere with 
the proper actions of the new functions to which reference has been made.- 
In these exceptional circumstances, when there is any uncertainty as to 
the character of the milk which the infant is taking, a chemical analysis 
should be made at once, and repeated several times at intervals of a few 
days. These latter months, though not so difficult to manage intelligently 
as the early period of the infant's life, are much more likely to need care- 



FEEDING. 159 

fill supervision than the middle period, which, from its usually uninter- 
rupted tranquillity, has been called the period of normal nutrition. 

When on account of an insufficient supply of milk in the mother the 
infant has for some time become accustomed to several meals of a substi- 
tute food daily, the matter of weaning becomes a very simple one, for we 
know that we have a food which will agree with it ; but when we have to 
begin to wean directly and to adapt a food to the infant's digestive capa- 
bilities, as in cases of sudden failure of the milk or of sickness in the 
mother, this procedure becomes much more intricate, and is at times 
fraught with considerable danger. It is in these cases that an analysis of 
the milk made when the mother was in good condition often proves to 
be of great assistance. 

The method of weaning which I have adopted, and have found to be 
the safest and best, is the one which I have been enabled to use since 
having a milk-laboratory at my command. My rule is, provided that the 
infant is thriving or digesting its mother's milk well, to order from the 
laboratory a substitute food the percentages of the elements of which are 
very similar to what the infant has been taking from its mother. After a 
few days, if this food is agreeing with the infant, a change should be made 
in the percentages of the different elements, with the object of gradually 
combining these percentages in such a way as to correspond to the per- 
centages of the elements of unmodified cow's milk. This is easily and 
precisely accomplished. For instance, supposing that the infant is re- 
ceiving from its mother a milk in which the percentage of the fat is 4, of 
the sugar 6.50, and of the proteids 2, we should begin by giving the same 
percentage of fat (4), a lesser percentage of sugar (5.50), and an increased 
percentage of proteids (2.25). After a few days, if this milk is digested 
well by the infant, the fat can be made 4, the sugar 4.50, and the proteids 
3. In a few more days, if this food is digested well, plain cow's milk, 
with lime-water sufficient to make it slightly alkaline, can be given. The 
milk which is now received from the farms connected with the laboratories 
is practically so free from bacteria that it need not be pasteurized in the 
winter months ; and often, also, in the summer, it will remain fresh, except 
in exceptionally warm weather, or when it has to be transported a long 
distance. If this still agrees with the infant, cow's milk without lime-water 
can be given. 

Unless under very exceptional circumstances, sudden weaning is to be 
deprecated, though of course we must admit that it is sometimes done 
with impunity. The safest method, so long as we cannot judge beforehand 
which infants will be likely to be unfavorably affected by sudden weaning, 
is to take plenty of time and gradually ascertain by frequent changes the 
food best adapted to the case. The infant should be gradually accustomed 
to this food, omitting the breast-feedings one by one, until finally we are 
sure that we have a substitute food on which it will thrive. At the tenth 
or eleventh month, provided that the weaning of the infant is deemed 



160 PEDIATRICS. 

desirable at so early a period, and after having accustomed it to take plain 
cow's milk, starch in some form can also be given. It will be necessary 
to determine how much of this new element may be introduced into. the 
infant's diet, carefully adapting the amount to its amylolytic function, 
which varies in different infants, and which has but lately arrived at its 
full development. When these changes have been accomplished, the 
breast can with safety be entirely withdrawn. 

The danger of injudicious weaning is illustrated by the following case : 

A delicate infant, backward in its development, digesting well, and a little over 
one year old, was suddenly deprived of the plentiful supply of breast-milk of its 
healthy mother and fed on oatmeal gruel. Vomiting and prostration immediately 
began, and continued until the oatmeal was omitted and the breast-feeding resumed, 
when the infant began to thrive again. Three weeks later the mother, through igno- 
rance, suddenly and without any preparation fed it again on oatmeal gruel. On the 
following two days the infant vomited incessantly and was much prostrated. Several 
changes were then made in its food, but the symptoms grew worse, and the mother, 
who was now very uneasy about the infant, again put it to her breast, with, how- 
ever, this time a disastrous result, as her milk from nervous influences was so changed 
in its quality that it acted like a poison on the infant, who fell into a condition of col- 
lapse. A wet-nurse with a healthy infant four months old was immediately procured, 
and after several days of complete prostration the foster-infant began to revive, and 
later was gradually weaned without trouble. It may be well to add, for the encourage- 
ment of physicians who have cases of this kind to deal with, that after the mother's 
milk had poisoned the infant, and when I first saw it, the skin was gray and cold, the 
fontanelle sunken, and the eyes fixed, yet recovery took place. Under the same cir- 
cumstances equal success in the treatment would probably be obtained by writing for 
a milk prescription to contain fat 2.50, sugar 5, proteids 0.50. This, of course, 
would be an exceedingly weak food for an infant twelve months old, but it would be 
the safest combination to begin with, and could be increased in strength as the infant 
recovered. 

II. DIRECT SUBSTITUTE FEEDING. 

WOMEN. — When for any reason it is impossible or inadvisable for 
the mother to nurse her infant, some other food must be substituted for 
the maternal. The milk of another woman approaches the mother's in 
its characteristics most closely, and should be obtained unless contra- 
indicated. 

It is generally supposed that the mother's milk, as a rule, is more 
likely to be suited to her infant's digestion than the milk of another 
woman ; but we have as yet too few cases where direct investigation by 
means of chemical analysis of the two kinds of milk has been made to 
lay down actually as a fact what we can merely grant as a supposition, 
that an idiosyncrasy in the mother's milk will find an analogue in her 
infant's digestive powers. The reverse of this proposition has also been 
held to be true, that at times some idiosyncrasy in the mother's milk will 
make it radically unfit for her infant. The probability is that analyses 
will show either that these varieties of milk are poor ones, or that the 
infants have unusually weak digestive powers. 



FEEDIXG. 161 

The fact that every mother cannot provide as good a milk for her 
infant as can be supplied by another woman finds its analogy in the ina- 
bility of some Jersey cows to rear their own calves. 

The following case illustrates how at times an idiosyncrasy of diges- 
tion in the infant corresponds to some unusual percentage in its mother's 
milk : 

The mother, a primipara, was healthy, but of a highly nervous temperament. The 
infant was thriving, but, as a measure of precaution in case of mammary disturbance 
at a later period of the lactation, an analysis was made of the milk, with the following 
result : 

Tat 5.16 

Sugar 5.68 

Proteids 4. 14 

Mineral matter 0.17 

Total solids „ 15. 15 

Water 84.85 

100.00 

The report made by Dr. Harrington in connection with this analysis was, "The 
precipitated curd is quite similar in its appearance to that obtained in the analysis of 
cow's milk." 

The mother was advised on general principles to take more exercise, and ten days 
later another analysis of the milk was made : 

Fat 4.88 

Sugar 6.20 

Proteids 3.71 

Mineral matter 0.19 

Total solids 14.98 

Water 85.02 



100.00 



The second analysis was so similar to the previous one that, in conjunction with the 
perfect digestion and health of the infant, it was concluded that this infant had an idio- 
syncrasy of digestion which enabled it to thrive on what would in most cases cause 
extreme disturbance. This view of the case proved to be correct, as the infant, which 
was under my care for a number of months, continued to thrive. A comparison of this 
analysis with that of the milk of the wet-nurse on page 164, where the high percentage 
of proteids caused vomiting of thick curds by the infant, will show a striking similarity 
of the two milks. There is no doubt that in the majority of cases a milk such as is 
represented by these two analyses would be totally unfit, and would not only cause 
marked indigestion but often more serious results, such as convulsions. 

The following case presents an illustration of the reverse of the sup- 
position that the mother's milk will suit her infant's digestion better than 
the milk of a wet-nurse : 

This infant was being nursed by its mother and showed continual disturbance of 
its digestion. At times it would be constipated, and again it would have attacks of 
colic with watery discharges. The colic was the most prominent symptom, and the 

11 



162 PEDIATRICS. 

child, though looking fairly well, was not gaining in weight. An analysis of the mother's 
milk showed that the percentage of fat was from 2 to 3, the sugar was of about the 
normal percentage, and the proteids varied from 3 to 3.50 per cent. The mother was 
of an extremely nervous temperament and was unwilling to carry out the rules for the 
management of her milk, which were absolutely necessary in order to reduce the high 
percentage of proteids, which evidently caused the disturbance. A wet-nurse was 
therefore procured, the analysis of whose milk was as follows : 

Fat 2. 96 

Sugar 5.78 

Proteids 1.91 

Mineral matter 0.12 

Total solids 10.77 

Water 89.23 

100.00 

The infant on taking this new milk ceased to have colic, but was more constipated 
and did not gain in weight. It was therefore decided that it would be wise to increase 
the percentage of the fat in the nurse's milk. This was done by giving her considera- 
bly more meat to eat and making her take moderate exercise. The infant within a 
week began to gain in weight and to sleep well, the bowels ceased to be constipated 
and were moved naturally every day. There was also a plentiful supply of milk. 
Another analysis of the milk was then made, with the following result : 

Fat 3.31 

Sugar 6, 45 

Proteins 2.36 

Mineral matter 0. 16 

Total solids 12.28 

Water 87. 72 

100.00 

This last analysis is of great significance. The increase in the percentage of the fat 
evidently regulated the faecal movements. The total solids increased from 10.77 to 
12.28, and the plentiful supply of milk made the infant gain, especially as it now was 
digesting perfectly. It was evident that it could digest, a milk with a percentage of pro- 
teids below 2.50, while it was a percentage of 3 in the mother's milk which prevented 
her from carrying on her lactation. 

In this case it will be seen that the milk of another woman was far preferable to 
that of the mother, and that the idiosyncrasy of a high percentage of proteids in the 
mother's milk did not find its counterpart in an idiosyncrasy in the proteid digestion of 
her infant. 

WET-NURSES. — The general question as to whether a wet-nurse 
shall be employed is one which is of serious import, and must in each in- 
stance be decided by giving full weight to all of the many circumstances 
which are involved in the case. Foster-feeding, when all the conditions 
are good, is superior to substitute feeding. The reverse of this statement, 
however, must always be kept in view, that a poor nurse, whether from 
temperament, or age, or general health, or the quality of her milk, had bet- 
ter be set aside when the conditions are favorable for a successful substitute 
feeding. It is perhaps better that the nurse's milk should correspond in 



FEEDING. 163 

age somewhat nearly to that of the infant she is to suckle, but a difference 
of some months in age may not be a contra-indication, as we are not yet 
in a position to say definitely that the milk differs sufficiently in different 
months to make this a reason of importance in choosing a nurse. A fee- 
ble child will nurse more easily and probably have better care from a 
multipara than from a primipara. The preferable age of the nurse is be- 
tween twenty and thirty years. Her other requisites are a condition of 
good health and a quiet temperament. It will save much trouble and 
often obviate the frequent necessity for changing if before her engagement 
we have made a chemical analysis of her milk ; in fact, all the points which 
have been already referred to for a successful maternal nursing are of 
equal significance in the case of a wet-nurse. 

The general health of the wet-nurse should be carefully investigated, 
as women suffering from constitutional syphilis or any chronic disease are 
manifestly unfit for nursing. At the same time we should be careful, un- 
less decided symptoms of disease are present, not to set aside the milk of 
a delicate-looking woman until it has been analyzed. The wet-nurse in 
the case just described, whose milk proved to suit the infant better than 
did its mother's, was a frail, delicate-looking woman, but healthy. The 
mother, on the other hand, was a large, strong-looking woman, but of a 
very nervous temperament. The rapid progress which is being made in 
the detection of the bacillus tuberculosis, not only in the sputum but also 
in the milk and in other secretions, may in the future be of much prac- 
tical importance in the determination as to whether a woman should 
nurse an infant or not, but the present state of our knowedge is only suf- 
ficiently advanced for us to state that this bacillus has been found in the 
secretion of the mammary gland of cows which have responded to the 
tuberculin test, and whose milk has been proved to be pathogenic in 
animal experimentation. 

Diet. — The same general principles that have been stated in speaking 
of the diet of the mother should be applied to that of the wet-nurse. We 
should be extremely careful not to change suddenly the customary diet of 
a healthy nursing woman on purely theoretical grounds. For many years 
the mistake was made of keeping women on too low a diet in the early 
period of lactation, with the consequent delay in the establishment of a 
sufficiently nutritious milk-supply, and a corresponding initial loss of 
weight in their infants. Where, however, we are especially likely to err 
is in permitting a healthy, hard-working wet-nurse, accustomed to a some- 
what coarse but nutritious diet, to adopt totally, different habits of exercise 
and a diet to which she is unaccustomed, rather than to have her continue 
her usual mode of life. This sudden change of habits frequently results 
in loss of health to the nurse, with its accompanying deterioration in the 
quality of her milk, or at least a change in its quality so as to make it an 
unfit food for her foster-child. A notable instance of too radical a change 
of habits was brought to my notice by a case seen in consultation. 



164 PEDIATRICS. 

A wet-nurse had been procured for an infant ten days old. An analysis of her 
milk, two days before she began to nurse, is shown in the following table. Her milk 
was digested well for two or three weeks, during which time she was fed on an abun- 
dance of good food and rich milk. The infant then began to vomit thick curds iden- 
tical in appearance and toughness with the curds of cow's milk. Another analysis 
was made, which showed the amount of total solids to be increased in a most marked 
degree, the percentage of proteids corresponding far more nearly to that of cow's milk 
than to that of woman's milk. The nurse was then given plainer food and skimmed 
milk, and the infant ceased to vomit. The infant and nurse continued well and 
strong during the whole year, the infant making a weekly gain in weight. 

Analysis I. Analysis II. Analysis III. 

Two days before Rich food for Food regulated and 

change of food. a month. mi } k agreeing with 

infant. 

Fat 0.72 5.44 5.50 

Sugar 6.75 6.25 6.60 

Proteids 2.53 4.61 2.90 

Mineral matter 0.22 0.20 0.14 

Total solids 10.22 16.50 15.14 

Water 89.78 83.50 84.86 

100.00 100.00 100.00 

Animals. — In parts of France, notably in Brittany, infants are put 
directly to the cow's teats, and sometimes with good results. I know of 
one family of eight children, all of whom were nursed by the family cow, 
and all of whom grew up healthy and strong. Yet the undesirability of 
feeding human beings directly from the udders of animals is so manifest 
that this method need not be discussed. 

m. ESTDIRECT SUBSTITUTE FEEDING. 
General Considerations. — I have laid great stress upon the importance 
of feeding infants during the early months of life by means of human milk. 
We know, however, that the necessity will often arise for supplying the 
infant with food not from the human breast. In all probability the em- 
ployment of substitute feeding will increase rather than decrease as our 
civilization advances. With this prospect before us, and appreciating the 
difficulties which in a large number of cases are liable to arise when we 
attempt to adapt a substitute food to the wants of an infant, it manifestly 
becomes a duty to endeavor to reduce the high mortality figures usually 
resulting from artificial feeding. With this purpose in view, we should care- 
fully investigate different methods of feeding and adopt some more uniform 
plan for starting human beings in life ; for diversity and not uniformity is 
now the rule. While inherited diseases contribute a certain proportion of 
the deaths which occur in infants, yet diversity of method in feeding is the 
most prolific source of disease in early infancy. The group of symptoms 
which for want of a better name is designated as difficult digestion occurs 
most frequently in the three periods in which the infant's digestion is likely 
to be tampered with, — namely, in the early weeks of life, when experi- 
ments are being made to determine what food will be best to start 



FEEDING. 165 

with ; next, when, in addition to the irritation arising from the beginning 
of dentition, new articles of diet are added to the original food ; and, 
thirdly, at the time of weaning, when there is often a sudden and entire 
change in the character of the food. The proper management of the first 
of these periods is of the greatest importance, because it is the time when 
the stomach is in its most active period of growth, and when the function 
of digestion is being established, and following the rule of functional estab- 
lishment, is in a state of unstable equilibrium. 

We should recognize the fact that the problem of substitute feeding is 
not a simple one. We cannot reiterate too often that the question which 
commonly is supposed to be a simple one, and the one which in the great 
majority of cases is alone considered, — namely, "Which food shall we give 
to the infant?" — is a misleading and insufficient one. The problem is a 
combination of factors of which the kind of food is only one, and I per- 
sonally have long been convinced that the neglect to investigate thoroughly 
and carry out in detail the combination of these by no means insignificant 
general factors has had much to do with our failures in subsitute feed- 
ing in the past. It would seem, also, that the present is a most opportune 
time for raising a note of warning against allowing our enthusiasm over 
any one especial theory to warp our better judgment. There will surely 
be a reaction which will relegate to its proper place every theory built 
upon single factors of the problem before us, and which is actually doing 
harm by keeping in the background other theories which, each in its own 
sphere, as a significant part of a complete whole, may be of very great 
importance in the successful solution of the general problem. An error of 
oversight of one-eighth in a mathematical problem is not so great as one of 
one-fourth, but nevertheless the correcting of the greater error will not 
prevent an oversight of the smaller from completely destroying a correct 
result. Until lately it has been the quality of the food which has been 
monopolizing to too great a degree the attention of the medical profession. 
Then it was sterilization in feeding which became prominent. A German 
writer on substitute feeding has stated that the physiology and pathology 
of infantile digestion depend not on the chemical but on the biological 
character of the food. If we are not on our guard, this exaggeration of 
each single factor will prevail, and by its influence will blind us to much 
good work which in other directions has already been done, and which 
we cannot afford to ignore. Not that I would for a moment be under- 
stood to underrate the value of feeding an infant on a sterile food, for it 
has for years proved of very great benefit in my practice and that of others, 
but I predict that by just so much as we enhance the value of this one 
important part of the whole at the expense of the others, just so much 
farther shall we be from an intelligent comprehension of the whole subject. 
To feed an infant one month old with six ounces of acid cow's milk every 
four hours, no matter how thoroughly such a mixture has been sterilized, 
would be a^ radical offence against well-known anatomical and physiologi- 



166 PEDIATRICS. 

cal laws. We should investigate and endeavor to copy, each in its turn, 
the various devices which nature makes use of, for we must admit that we 
are not in a position to improve on nature's method. 

It is certainly wiser and more economical not to spare expense and 
trouble in arranging the infant's diet, for the period of active growth of an 
organ is the time when its function is readily weakened, and when once 
weakened, the digestive function is a prolific source of annoyance and ex- 
pense in childhood and adolescence. Cheap foods and cheap methods of 
feeding, unless they are the best that can be procured, should not be tol- 
erated in the early feeding of infants. We often, however, see a food 
recommended for a young infant because it is cheap and easily prepared, 
in spite of the fact that its well-known lack of nutritive ingredients should 
stamp it as unfit for use. 

In discussing the treatment of disease we advocate what is best, with- 
out reference to what it costs, and then, in the special case where expense 
is an element which has to be taken into consideration, we endeavor to 
adapt our treatment to these considerations, and approach as nearly as 
possible to our first standard. In like manner I believe that we are doing 
wrong to the public if we allow ourselves to be handicapped in so difficult 
a question as infant feeding by the cry of expense. Infant feeding is an 
expense which is vital to the welfare of the human race, and we can, 
without being accused of extravagance, safely relegate to the province of 
the manufacturers of patent foods the recommending to the public of 
foods which if judged by the amount that is offered in bulk are cheap, 
but which when judged by their nutritive properties are extremely ex- 
pensive. 

Our scientific knowledge and clinical investigations have not yet en- 
abled us to follow nature exactly, and we therefore have not yet obtained 
an ideal method of substitute feeding. We must, nevertheless, go as far 
as the present state of our knowledge will allow, thus gaining a little 
ground every year ; and we must be especially careful not to be led astray 
by the fictitiously brilliant results which are reported from time to time 
in favor of certain foods. Instances are continually occurring where one 
food will fail and another, when substituted for it, will succeed, and yet 
these successes are merely temporary, and the disturbances of nutrition 
and mortality resulting from the use of various infant foods always re- 
mains far above those which occur from the use of human breast-milk. 

Source of Food. — Having decided to substitute some food in place of 
woman's milk for the infant, we must decide from what source the ele- 
ments of this food shall come. The food which approaches most nearly 
in every respect the product of the human mamma is that produced by 
the mammae of other animals. The reason for this is that the food which 
all mammals provide for their offspring is an animal one, and consists of 
the same elements, although the mammary product of different animals 
varies in the percentage of these elements. 



FEEDING. 167 

Assuming, then, that average human breast-milk is the safest standard 
for us to copy, we are impressed with the fact that although a vegetable 
diet would often seem far the easiest method of procuring nourishment 
for young infants, yet nature has persisted in providing an animal one. 
We should therefore be very careful not to introduce into our substitute 
diet a vegetable element, which, as judged by our standard, must be a 
foreign element. Milk is the food which our reason tells us should be 
given to the young infant and a milk which will approach as nearly as 
possible to the average human milk. 

The milk of various animals has from time to time been recommended 
as the best substitute for human milk, the recommendation being based 
on their analyses approaching more or less nearly the composition of 
human milk. The milk, however, of all animals has to be modified to 
correspond to human milk ; and when we begin to modify, it is as easy to 
change the percentages of the different constituents to a great degree as to 
a small. The fact that the milk of any particular animal approaches in 
its analysis nearly to that of the human breast is not of much significance, 
other considerations being far more important ; and it is most important 
of all that we should use one which can be obtained easily by the people 
at large. This at once settles the question that it is the milk of the cow 
to which we must turn our attention, even though cow's milk may differ 
in its composition from human milk to a greater degree than does the 
milk of the ass or the mare, whose milk approaches, so far as is shown 
by analyses, most nearly of that of all animals to human milk. If, how- 
ever, the ass and the mare should be employed for dairy purposes to the' 
same extent that the cow has been, there is every reason to suppose that 
their milk might change in its composition and their comparatively unde- 
veloped mammary glands increase in size, just as has been the case with 
the cow, an animal which for thousands of years has been used for the 
production of milk, and which probably did not in the beginning give such 
an over-production of the mammary secretion as is the case now. It is, 
then, from the public demand, and by breeding, that cows have been 
made to produce so much more milk than is necessary for the support of 
their young. Not only quantitative but qualitative differences exist in 
animals according to the development of their mammary glands ; and, as 
Martin y has shown in his collection of statistics on this subject, the con- 
dition which determines the quantity and the quality of the milk depends 
on the development of the organ which produces it. 

A further exemplification that cow's milk is practically the universal 
source of the substitute food-supply for infants in most civilized commu- 
nities is the fact that the various foods, patent or not, all depend for their 
basis on cow's milk, and that without this addition of milk they would 
show but an insignificant percentage of many of the most important in- 
gredients of the food. Logically we should not speak of the various foods 
as such, but merely as adjuvants to cow's milk. If this is thoroughly 



168 PEDIATRICS. 

understood, much misapprehension regarding the apparently successful 
results of innumerable foods will be done away with. 

Another reason for using cow's milk in preference to all others is 
owing to the fact that the cow can be kept under more strict control than 
any other mammal. 

THE COW. — Having chosen the cow for our primal milk-supply, we 
must next consider whether any special breed is better adapted than 
others for accomplishing our purpose. To do this we should first examine 
chemically and microscopically the elements of the milk of those breeds 
which can be employed best throughout the civilized world. It has been 
found that the finer breeds of cows from the Channel Islands are more 
liable, when transported from their home to countries where the climate 
is more severe, to contract diseases, such as tuberculosis, than are the 
animals represented by the Durham, Devon, Ayrshire, and Holstein 
breeds. 

Among the breeds of cows which should be used for infant feeding at 
the farms connected with the laboratories are the following. 

The Durham, or Shorthorn, represents the best type of cow for this 
purpose. She has great constitutional vigor, great capacity for food, a 
perfect digestion, a placid temperament, and yields a large quantity of rich 
milk, of which the analysis is as follows : 

Per cent. 

Fat 4.04 

Sugar 4. 34 

Proteids 4.17 

Mineral matter 0. 73 

Total solids 13.28 

Water 86.72 

100.00 



Another breed, the Devon, has the same general characteristics as the 
Durham. The cows are gentle and vigorous, and give a moderate quantity 
of milk of medium quality, the analysis of which is as follows : 

Per cent. 

Pat 4.09 

Sugar 4.32 

Proteids 4.04 

Mineral matter 0. 76 

Total solids 13.21 

Water 86.79 

100.00 



Another breed is the Ayrshire, whose constitutional vigor is great, but 
whose temperament is nervous. The cows are not so hardy as the Dur- 
ham, but are very free from disease. They yield a large supply of milk 
with the following analysis : 



FEEDING. 169 

Per cent. 

Fat 3.89 

Sugar 4.41 

Proteids 4.01 

Mineral matter 0. 73 

Total solids . . 13.04 

Water 86.96 

100.00 

Another breed which is of a thorough dairy type is called the Holstein- 
Friesian. This cow represents the most perfect milking animal known, 
having every characteristic of a cow suitable for laboratory purposes, but 
her milk is so light in its total solids that it is not so profitable as the 
other breeds. She yields a larger quantity of milk than any other known 
breed, although the analysis shows it to be poorer in quality. The follow- 
ing is the analysis : 

Per cent. 

Fat 2. 88 

Sugar 4. 33 

Proteids 3.99 

Mineral matter 0. 74 

Total solids 11.94 

Water 88.06 

100.00 

Another breed is called the Brown Swiss grade. The cows are very 
vigorous, healthy, and docile, and yield a fair supply of milk of about the 
richness of the Devon, the analysis of which is as follows : 

Per cent. 

Fat 4.00 

Sugar 4.30 

Proteids 4.00 

Mineral matter 0. 76 

Total solids 13.06 

Water 86.94 

100.00 

Finally, we can make use of the little Bretonne cow, known all over 
Europe as the "cow for the family." Cows of this breed have all the 
characteristics of the good domestic cow which have already been men- 
tioned. They produce a medium amount of milk, large, however, in pro- 
portion to their size. 

Some of the marks which distinguish the breeds of cows best adapted 
for infant feeding are : (a) constitutional vigor, (6) adaptability to acclima- 
tization, (c) notable ability to raise their young, (d) freedom from intense 
inbreeding, (e) a distinctly emulsified fat in the milk, (/) a preponderance 
in the fats of the fixed glycerides over the volatile glycerides. The vola- 
tile glycerides do not exist in the mammae, but are formed in the milk soon 
after the milking. In some breeds, as in those of the Channel Islands, 
this change occurs more quickly than in others. Such breeds as the Jer- 
sey, Guernsey, and any others in which intense inbreeding has been car- 



170 PEDIATRICS. 

ried on and in which acclimatization has not been perfected, should not 
be used for infants and young children. These breeds, of course, do 
not represent all of those available for substitute feeding, for we may 
mention many others equally good each in its country. For example, 
the Kerry of Ireland, the Red Polled of England, the Dutch Belted and 
the Flemish, also the Flamande and the Cotentine of France, the Nor- 
man breed of Normandy, besides the Brown Swiss just spoken of, and 
the Simmenthal, sometimes called Bernese, of Switzerland, also the Chia- 
nina of Italy, and the Allgauer of Germany. The native cow of this 
country, the " Red Cow," through many generations of neglect and ex- 
posure in winter, has undoubtedly acquired an impaired digestion and 
does not respond readily to appropriate changes of food. 

Care of the Cow. — A cow whose milk is to be used for purposes of 
infant feeding should be properly housed and well cared for, as the do- 
mestic cow is an animal peculiarly sensitive to her surroundings, and her 
product is correspondingly liable to be thrown out of equilibrium. The 
milk product of a herd of healthy cows is much less liable to the varia- 
tions so injurious to the infant's digestion than is the milk of any one 
cow. It is especially to be noticed how much easier it is by proper care 
to control exaggerated nervous influences upon the cow's product than 
upon the woman's. This at once suggests to us the question, Where and 
how shall cows be taken care of? 

The cow is a sensitive animal, easily yielding to conditions good or bad 
in which she is placed. She is liable to contract diseases communicable 
to man, and especially to infants, and she is a ready vehicle for the trans- 
mission of obscure and often untraceable affections of a septic character. 
Her surroundings are such as to favor infection, and her attendants are 
often the means of conveying to the milk many of the transmissible dis- 
eases, such as scarlet fever, diphtheria, and tuberculosis. 

The ordinary cow is allowed to range over wide pastures which are 
sometimes overflushed with herbage and sometimes parched by drought, 
and which nearly always contain noxious weeds, which she seems eagerly 
to seek. Again, she is forced to drink from stagnant pools and polluted 
streams, and at other times suffers for want of water for many hours to- 
gether. She is also frequently exposed to storms. Cows cared for in this 
way are not those which provide the best milk for substitute feeding. 
These are the adverse conditions which surround the ordinary cow during 
the summer. In the winter she is crowded in the stifling atmosphere of a 
close barn with the manure of the whole winter kept underneath the floor 
on which she stands. Her head is usually confined in a narrow stall. 
The fodder intended for the winter's supply is kept above her head, and 
is continuously contaminated by the foul odors of the barn. She is turned 
out to the watering-trough at periodical intervals. Thus she cannot be 
said to be cared for in a manner conducive to the equable function of her 
mammary gland. 



FEEDING. 171 

For cows to be used for the purpose of infant feeding a barn is needed 
where each cow shall have at least twelve hundred cubic feet of fresh air. 
The food should be kept where it cannot be contaminated. The manure 
should be as carefully removed from the barn as if it were a human dwell- 
ing. The cow should have freedom for her head and limbs in wide stalls. 
Large, dry, sunny exercise-yards should be provided for her. Her food 
should always be brought to her and selected with great care. Pure 
water should be provided, and suitable cups or troughs containing running 
water should be in her stall. The bedding should be fresh and free from 
mould or from any soil productive of bacterial growth. Methods should 
be used to get rid of all the usual foul odors and free ammonia so com- 
monly produced in barns. Cows should be carefully guarded against 
fright, the worrying of dogs, and unusual excitements of all kinds, which 
cause serious disturbance of the lacteal functions of domesticated cows, in 
contradistinction to those of cows in a more natural condition, as, for in- 
stance, the cows in a semi- wild state on the plains of Montana, Texas, 
Australia, and the Pampas of South America. Excitement does not ap- 
parently injure the lactation of these cows, while it inevitably throws out 
of equilibrium the milk of the well-cared-for dairy cow. If the same 
care should be applied to regulating the woman's life as can be employed 
in the barn, we should encounter fewer difficulties in human breast-feed- 
ing. The feeding of the cows should have for its object the production of 
an even, nutritious, digestible milk and the careful avoidance of over- 
stimulation of the lacteal secretion. The exact chemical analysis of any 
one ration used for feeding cows for our purpose must be carefully consid- 
ered in accordance with the ratio of the digestible nutrients of the fooa, 
and this must of course be arranged practically from the recognized food 
tables. A great variety of food is necessary in feeding cows, but in the 
transition from green foods to dry, or the reverse, much care is needed to 
graduate the change, as disturbance in the equilibrium of the mammary 
gland is rapidly followed by injurious effects on the consumer. In past 
times, before I could rely as I do now on this carefully managed change 
of rations, the spring of the year with its flush pasturage and the fresh 
grass following the autumn rains were fruitful sources of infantile digestive 
disturbance in my nursery practice. 

All these links in the chain which constitutes a successful substitute 
feeding are of great importance. The cows must be kept clean by groom- 
ing and the necessary washing, the precaution always being taken to 
rub the moistened parts dry. The milkers should be dressed in clean, 
freshly sterilized white suits and caps. Their hands and arms should be 
thoroughly scrubbed before milking. The hands in milking should be 
kept dry. The milking-stools should be made of metal so that they can 
be sterilized. The milk should be drawn with some force, simulating the 
action of the calf, and at each milking every drop of milk should be drawn 
out. The milk should be drawn into sterilized pails and carried imme- 



172 PEDIATRICS. 

diately from tne barn to the milk-house, which should be a sufficient dis- 
tance from the barn to be free from odors. No means yet known to 
science can prevent some few bacteria coming into the milk during the 
milking-time, though it is possible to reduce the number so greatly as to 
make the milk practically sterile for the purpose of infant feeding, par- 
ticularly if the second half of the product of the udder alone is used and 
milked into sterile tubes. The first half probably contains many bacteria, 
which, entering from without, have reached the lower portion of the teat. 

The major part of the bacteria present in the milk are such as cause 
the usual acid fermentation which we recognize in the common souring of 
milk, but there are many species of bacteria which ought to be prevented 
from gaining access to the milk, arising from mouldy hay, straw, or fodder, 
partially decayed roots, and the natural decay of the wood-work of the 
barn and adjoining buildings. These latter varieties, which are found to 
be especially inimical to the preparation of substitute foods, cause in some 
cases the alkaline fermentation and other abnormal conditions of milk. 
Every barn apparently has its own set of bacteria, and the flora in Amer- 
ica do not exactly resemble the analogous European species which have so 
often been described. 

The bacteria which are found in cow's milk do not necessarily come 
from external sources, whether they be of the cow herself or of her sur- 
roundings, but may also come from some part of the milk tract between 
the udder and the end of the teat. These conclusions, it may be said, are 
made with reference to healthy cows. 

Infectious mammitis, to some extent, seems clearly to be carried by the 
hands of the milkers from cow to cow. This also points to the fact that 
bacteria may find their way to the ducts through the teats. 

Tuberculin Test of Cows. — It is very important that certain precau- 
tions should be taken to prevent the use of cows which are affected with 
tuberculosis. It is probable that three per cent, of the cows whose milk 
is used for food are tuberculous. Where tuberculosis is developed to such 
a degree in the cow as to be dangerous to the consumer of the milk, the 
disease can be usually detected by a skilful veterinarian by means of the 
physical examination which is employed in cows. But, as it is a disputed 
question at present as to when the milk of a tuberculous cow becomes 
affected, it is wiser to adopt all measures of precaution known to science. 
Of these measures the one which is most efficacious in detecting even the 
incipient stages of tuberculosis is the "tuberculin test." All the cows in 
use at the farms of the milk-laboratories are subjected to this test, and 
unless a negative reaction is obtained they are isolated from the rest. of 
the herd. 

Care of the Milk. — After the cows are milked, the milk should be 
carried quickly from the cow to the milk-house, which should be at least 
a hundred yards from the barn and completely isolated from all other 
buildings. To prevent the milkers from going into the milk-room, the 



FEEDING. 173 

milk at the farms connected with the milk-laboratories is poured by means 
of a block-tin pipe through the wall of the milk-room into a large ice-lined 
block-tin tank, which is also the mixer for the milk of the entire herd. In 
the space of four minutes, by means of an ice-jacket, the milk is cooled 
from 33.88° C. (93° F.) to below 4.44° C. (40° F.). This is to rapidly 
remove the heat, which is conducive to bacterial growth. The milk 
passes through eight, thicknesses of sterilized gauze on its way to the tank. 
The milk-room is practically clean from a bacteriological stand-point, for 
the walls and floor are kept wet with clean water, and all dust is ex- 
cluded. The air which enters the milk-room is washed with sterilized 
water as it enters. Part of the milk is then passed through the separator, 
while part is drawn into sterile jars for transportation. No one is allowed 
to enter the milk-room except the man in charge, and he is carefully 
trained to be absolutely clean in person, taking special care of his hands, 
face, and hair. While in the milk-room he wears freshly sterilized white 
clothes. In the milk-room the jars are sealed, packed in ice, and in a few 
hours delivered at the laboratory. 

After milk has been treated with these precautions, I have had re- 
peated bacteriological examinations made on its arrival at the laboratory, 
with the uniform result that it has proved to be comparatively sterile, 
and at times it has contained either no colonies of bacteria or only one 
or two. 

No antiseptic can, without danger to the infant, be used about the 
cow* while all the mechanical devices heretofore tried to take the place 
of manual milking have inevitably tended to impair the lacteal function of 
the udder. 

CHEMISTRY OF COW'S MILK. — We have spoken of milk in 
general, and of certain points in connection with the chemistry of human 
milk in considering the subject of maternal feeding. In indirect substitute 
feeding, which involves a consideration of the principles governing the 
modification of cow's milk, it is of the first importance that the physician 
should acquaint himself with the chemical, physiological, and bacterio- 
logical characteristics of the food with which he is dealing. The failure to 
appreciate the importance of such a knowledge is responsible for much of 
the ill-founded criticisms of those who oppose the methods of percentage 
feeding, and the failure to obtain satisfactory results by those who have 
attempted to adopt percentage feeding without understanding its funda- 
mental principles. It is, therefore, well worth our while to consider in 
more or less detail certain points bearing on the chemistry of cow's milk. 

Average Analysis. — The following may be accepted as a fair average 
of the composition of cow's milk : 

Eeaction Slightly acid. 

Specific gravity 1029-1083 

Water 86-87 per cent. 

Total solids 14-13 " 



174 PEDIATRICS. 

Per cent. 

Fat „ 4.00 

Sugar 4. 50 

Proteids 3. 50 ■■ 

Total mineral matter 0. 70 

Chlorine 13.45 

Sulphur 0.41 

Phosphoric acid 27. 98 

Iron oxide and alumina 0. 44 

Lime 23. 17 

Magnesia 2. 63 

Potassium „ 53.00 

Sodium 4. 49 

Reaction. — Perfectly fresh cow's milk is generally amphoteric in re- 
action, but on exposure to air becomes more and more acid, owing to the 
formation of lactic acid by the action of certain micro-organisms upon the 
milk-sugar. The relative proportion of the acidity and alkalinity of the 
amphoteric reaction varies in different cows and at different times during 
the period of lactation, and is undoubtedly influenced by the character of 
the food on which the cow is fed. Experiments seem to show that the 
milk drawn from cows fed on the better grasses in a half-ripe condition 
is much more alkaline than when the cows are fed on dry fodder and 
grain, which increase the acidity of the milk. 

These experiments are of great interest as showing that not only can 
the product of the cow, so far as its reaction is concerned, be made to 
correspond to that of human beings by means of perfectly natural feeding 
and under perfectly normal conditions, but that this alkaline modification 
can be produced to such a degree that one-third of the milk is sufficient 
to destroy by its alkalinity the acidity of the remaining two-thirds. It is 
doubtful, however, if it is desirable to attempt to modify the reaction of 
milk for infant use by any such method of feeding. 

The importance of the subject lies in the well-recognized fact that the 
infant's digestive functions have been from time immemorial better adapted 
to the digestion of an alkaline or a neutral fluid than of an acid one.. 
Whether the moderately alkaline reaction of human milk is an important 
factor in the problem of infant feeding is a question which future investi- 
gation alone can completely prove, but with our present knowledge we are 
not prepared to dispense with even the least important of the many factors 
which make up this problem. At any rate, we should be very suspicious 
of a breast-milk which shows an acid reaction. In the preparation of an 
infant's food from cow's milk, according to the latest experiments by 
means of modification, the best results have been obtained by making the 
reaction of this food correspond to that of normal human milk. This, up 
to the present time, has been done best by the addition of an alkali, which 
is the only foreign element that it has been found necessary to employ. 

As it is wise in preparing a mixture for substitute feeding to make such 
a mixture approach as closely as possible in both taste and reaction to 



FEEDING. 175 

woman's milk, Harrington's experiments made at my request (Table 39) 
with lime-water and ordinary cow's milk twenty-four hours old are im- 
portant. Lime-water was the alkali used in these experiments because it 
is the most simple adjuvant which we can use for making cow's milk alka- 
line, the amount of lime contained in it being so small that its addition in 
even considerable quantity does not materially alter the amount of the 
total mineral matter. As small an amount as one-sixteenth part, when 
added to ordinary milk, will render it alkaline, so that for making an acid 
milk correspond in its reaction to woman's milk, lime-water is of great 
value, as it apparently does not produce any other changes in the milk. 
In addition to this, the taste of a mixture which is made from ordinary 
cow's milk, so as to correspond to the composition of woman's milk, is 
strikingly like that of woman's milk if it contain one-sixteenth part of 
lime-water. 

Harrington has made an estimate by actual experiment of the amount 
of lime-water which is needed to produce an alkalinity in a mixture such 
as has been just mentioned which would correspond to the alkalinity of 
human milk. This table (Table 39) shows the results of his experiments. 

TABLE 39. 
Amount of Lime- _, 

Water in Mixture. Reaction. 

25 per cent Strongly alkaline. 

12.5 per cent Still strongly alkaline. 

6.25 per cent, Slightly but distinctly alkaline, and 

corresponding to woman's milk. 

It must be remembered that these proportions of lime-water are those 
required for ordinary milk twenty-four hours old, a much smaller propor- 
tion being needed to produce the same results when the milk is collected 
and handled with the precautions insisted upon at the farm connected with 
the milk-laboratories. 

Specific Gravity. — The specific gravity of cow's milk varies from 
1.028 to 1.034, and does not differ materially from that of human milk. 

Milk-Pat. — The fat of milk occurs as minutely divided globules, held 
in suspension in the milk-plasma, forming a fine emulsion. It is defi- 
nitely proved that all of the fat occurring in the milk is contained within 
these globules, but whether the globules are purely fat is a disputed point. 
According to Storch, the globules are surrounded by a slimy substance 
called " stroma substance," which, by his analyses, is shown to be neither 
casein nor lactalbumin, but a nitrogenous material containing fourteen per 
cent, of nitrogen and a reducing substance on boiling with mineral acids. 
The fat is composed for the most part of the neutral palmitin, olein, and 
stearin, and the triglycerides, myristic, butyric, and caproic acids, with 
traces of other unimportant fatty acids and extractives. The percentage 
of fat in the average cow's milk and in the average human milk is practi- 
cally the same, i.e., about four per cent. The glycerides of the fatty acids 
composing the fat in both cow's milk and human milk have been deter- 



176 PEDIATRICS. 

mined, yet our chemical and clinical knowledge of the nutritive value and 
digestibility of these, separately or collectively, has not arrived at a point 
where we can practically make use of this knowledge, and we therefore 
direct our attention to regulating in a milk modification the percentage of 
the fat as a whole. 

Fig. 51, page 204, a photomicrograph of a thin layer of milk, shows 
the minute globules of fat permeating the transparent medium. This fat 
is simply held in suspension, which enables us to separate it easily by 
mechanical means. It is, in fact, in the condition which marks the milk 
as an emulsion. 

Milk-Plasma. — The milk-plasma is the fluid in which the fat globules 
are suspended. It contains the caseinogen, lactalbumin, lactoglobulin, 
milk-sugar, and various extractives, such as urea, creatin, creatinin, hy- 
poxanthin, lecithin, cholesterin, citric acid, and certain mineral bodies and 
gases. Clinically, we cannot, in our present state of knowledge, state the 
significance of the presence of these bodies, though they undoubtedly are 
factors in the general metabolism of the body. The milk-sugar, caseino- 
gen, and lactalbumin are, on the contrary, of the first importance, and their 
nature should be clearly understood. 

Milk-Sugar or Lactose. — The sugar of milk in all mammals is of the 
variety called milk-sugar or lactose. It is a simple and uniform element 
to deal with. Its percentage in cow's milk is about 4.5, and in woman's 
milk about 7. 

Regarding the kind of sugar which should be used in making up a sub- 
stitute food, we have certain questions to consider which would seem to be 
important. Cane-sugar has been, and still is, a favorite form with which to 
regulate this part of the solid constituents of the food. The reasons given 
for using it have been its preservative qualities, as seen in the manufacture 
of condensed milk, and the theory that it is not liable to set up excessive 
so-called lactic acid fermentation, with its consequent disturbance of diges- 
tion, as has been supposed to be the case with milk-sugar. Cane-sugar in 
a concentrated form, as it is found in condensed milk, seems to act as a 
preservative, but when it is diluted, as in its administration to the infant, 
cane-sugar ferments very readily, and in this respect has no advantage 
over milk-sugar. Reasoning from analogy, we should say that as milk- 
sugar is the only form of sugar found in the milk of mammals, it is there for 
some good purpose, and that it is needed for the accomplishment of some 
process which takes place after the food has been swallowed. Both cane- 
sugar and milk-sugar are converted into glucose either in the intestine or 
in the process of absorption from the intestine. There seems, however, 
to be some difference in the degree to which they can be used for pur- 
poses of nutrition before they are converted into glucose. So far as is 
known, whether in plants or in animals, cane-sugar is merely a reserve, 
and cannot be used directly for nutrition. Milk-sugar, on the other hand, 
is probably not merely a reserve, but may possibly be utilized in the econ- 



FEEDING. 177 

omy also for nutrition. Thus, Bernard has shown that seven grains of 
milk-sugar dissolved in an ounce of water could be injected under the 
skin of a rabbit without the subsequent appearance of sugar in the urine, 
while under the same conditions and in the same amount cane-sugar was 
found to be eliminated as foreign matter by the kidneys. 

Milk-sugar undergoes no direct alcoholic fermentation except when ex- 
posed to certain unusual ferments, but it changes readily to lactic acid in 
the presence of nitrogenous ferments. The lactic acid fermentation may 
be checked by heating the milk. Cane-sugar, on the other hand, easily 
undergoes alcoholic fermentation, but changes to lactic acid less readily 
than milk-sugar. Cane-sugar, moreover, takes on the butyric acid fer- 
mentation more readily than does milk-sugar. The bacillus lactis aerogenes 
(Escherich) is present in normal digestion, and acts on the milk-sugar to 
produce an organic acid which drives out the more noxious forms of 
bacteria, which by their presence Avould interfere with normal digestion. 
When milk-sugar is converted into glucose and galactose, we physiologi- 
cally have a gradual conversion into lactic acid, Avhich may aid in the 
digestion of the proteids, thus giving us a very valuable addition to the 
means at our command for rendering modified cow's milk digestible. 

Jeffries says, in reference .to the different actions of the various kinds of 
sugar in the digestive tract, that it is important to note that starch, dex- 
trin, inulin, cane-sugar, and dextrose afford material for the butyric acid 
fermentation, while milk-sugar does this only after completed hydration. 

Escherich, in speaking of Brieger's bacillus, says, " Milk is coagulated 
with sour reaction first after several days (eight to ten) at the body tem- 
perature. With exclusion of air this bacillus cannot grow either in milk 
or milk-sugar solution, but will in grape-sugar. 

We thus see that the milk-sugar offers less danger of the butyric acid 
ferment, which we know makes much trouble at times in the body, and 
that under certain conditions of the intestine it should be exempt from 
the assaults of Brieger's bacillus. 

When we consider that by means of heat we can practically put an 
end to the lactic acid fermentation, which may have begun to act upon 
the milk before it enters the stomach, it would seem that we are justified, 
on both physiological and bacteriological grounds, in using the same 
animal sugar in substitute feeding that is found in the infant's natural 
food, instead of introducing a vegetable sugar, which in milk is a foreign 
element. 

The dangers from lactic acid are, at any rate, much exaggerated by 
writers on this subject. 

Proteids. — The proteids of normal human milk belong to the nucleo- 
albumins, and have quite a wide range in their variation ; still, it is now 
well recognized that their average normal total percentage is very much 
below that of cow's milk. Assuming that the percentage of proteids in 
human milk is 1.5, or between 1 and 2, it can be stated that the relation 

12 



178 PEDIATRICS. 

of the percentage of the proteids in cow's milk and in human milk is as 
4 to 1.5. 

The proteids represent the nitrogenous elements of milk They con- 
sist of two distinct elements, caseinogen and lactalbumin (for clinical pur- 
poses it is not necessary to consider the lactoglobulin as separate from 
the lactalbumin), which together make up the total percentage of pro- 
teids in both woman's and cow's milk. These two elements differ greatly, 
however, in their relative proportions to each other in the two milks. 
This difference is shown in the following figures taken from Konig : 

Woman's Milk. Cow's Milk. 

Per Cent. Per Cent. 

Caseinogen 0.59 2.88 

Lactalbumin 1.23 0.53 

Total proteids 1.82 3.41 

According to the observations of other investigators the proportion of 
lactalbumin in whey is one per cent. (Bulletin 28, United States Depart- 
ment of Agriculture), which gives a higher percentage than in the figures 
quoted from Konig. Another analysis of whey by Hammarsten gives the 
percentage of lactalbumin as 0.86. 

Thus it is seen that of the total nitrogenous constituents of milk which 
are classed under the general term proteids, and of which the caseinogen 
and lactalbumin are parts, the coagulable proteids or caseinogen in cow's 
milk are proportionately larger in amount than in human milk, so that 
under the same conditions a larger curd will be formed with the former 
than with the latter. 

The question whether the casein in all milk is the same, or whether 
there are several different caseins according to the difference in the species 
of mammals, has not been determined. 

The casein is precipitated from its solutions by acids, but the precipita- 
tion is retarded by the presence of neutral salts. It is soluble in small 
excess of hydrochloric acid, but is again precipitated by a large excess. 

This acid coagulation of milk is to be clearly distinguished from the 
coagulation which takes place as a result of the action of the rennet fer- 
ment, by which the milk, when fresh, coagulates into casein and " sweet 
whey" without any change in its reaction. 

Mineral Matter. — The mineral matter of cow's milk has been ana- 
lyzed with comparative care and success. The total salts obtained by the 
analyses of Konig was 7.1 parts in 1000 parts, or 0.71 per cent. According 
to Soldner, the potassium, sodium, and chlorine are found in the same 
quantities in whole milk as in milk-serum. Of the total phosphoric acid, 
38 to 56 per cent., and of the lime, 53 to 72 per cent., is not in solution. 
A part of the lime is combined with the caseinogen ; the remainder is found 
united with the phosphoric acid as a mixture of dicalcium and tricalcium 
phosphate, which is kept dissolved or suspended by the caseinogen. The 
bases are in excess of the mineral acids in the milk-serum, and the excess 



FEEDING. 179 

of the former is combined with organic acids. At present the percentage 
of the mineral matter in cow's milk does not enter into the clinical modi- 
fication of milk, but a more extended knowledge of the subject may in the 
future be found to be of importance. 

The differences between the constituents of the mineral matter of 
human milk and of that of cow's milk are as follows : in cow's milk there 
are more lime, magnesia, potassium, much more phosphoric acid, and less 
chlorine and sulphur. 

Water. — There is about one per cent, less of water in cow's milk than 
in human milk. Chemical analyses invariably show so large an amount 
of water in human milk that it is evident that the infant is intended to take, 
and can best assimilate, a very dilute food. We must bear this fact in 
mind in preparing a substitute food, as the precaution of supplying a 
thoroughly diluted food is of extreme importance in managing the infant's 
feeding both in health and in disease. 

Total Solids. — There is about one per cent, more of total solids in 
cow's milk than in human milk. These solids in the milk are held partly 
in solution, partly in semi-solution, and partly in suspension. 

Attenuants. — So much has been said about, and so many physicians 
are in favor of, diluting cow's milk with such attenuants as barley-water 
and other cereal waters, that a clear understanding should be had as to 
the true position which such attenuation should hold in infant feeding. 

One of the objects which physicians expect to attain with cereal at- 
tenuants is that in some mechanical way the attenuant breaks up the 
coagulated proteids into finer particles than when the milk is simply diluted 
with water or lime-water or solutions of sugar. Barley-water seems to 
be the best attenuant for this purpose, and in comparing the coagulum 
obtained by the dilution made with this cereal with that made with water, 
lime-water, or sugar-water, it is found to be somewhat finer in the 
former than in the latter. The barley-water should be made as directed 
on page 239. A decoction of barley-water made in this way contains 
rather less than one per cent, of starch. This proportion of starch does 
not add materially to the nutritive value of the mixture, and must merely 
be looked upon as a foreign element which is never found in human milk. 
If, as has also been recommended by certain physicians, this starch in the 
cereal attenuant is dextrinized, the attenuant becomes a solution of sugar, 
and has no more mechanical effect on the coagulum than sugar in water. 

The use of cereal attenuants, excepting when they have a higher 
starch percentage for purposes of nutrition, is chiefly confined to the 
practice of those physicians who have not made an extended study of the 
finer possibilities comprehended in laboratory modification, and have failed 
to appreciate that the older methods of treating the coagulum of cow's 
milk are not needed in the newer. Human milk never contains starch ; 
the amylolytic function of the infant is not fully developed in the early 
months of life, and should not be taxed in the process of its development. 



180 



PEDIATRICS. 



The small additional mechanical effect of cereals on the coagulum is in- 
significant in comparison with the more rational methods of treating the 
coagulum ; these are truths which the medical profession will acknowledge 
when the laboratory system is better understood and laboratory methods 
still further perfected. 

The newer and more rational methods just referred to of dealing with 
the coagulum are not only to dilute sufficiently with water, but so to treat 
the total proteids in the mixture that the relative proportion of lactalbu- 
min and caseinogen shall approach as nearly as possible to that which is 
supposed to exist in the proteids of human milk. In this way the pro- 
portion of caseinogen being very much lessened, the resulting coagulum 
of casein will be much smaller, and practically so fine that any mechanical 
attenuant becomes useless. 

If cow's milk is diluted with simple water 1 part to 3, the resulting 
coagulum is a little larger than the coagulum of human milk. If, how- 
ever, the dilution is 1 to 4, the resulting coagulum is finer than that of 
human milk. In either case, however, the size of the coagulum must 
differ still further if the high percentage of caseinogen in the cow's milk 
proteid is reduced to the relative caseinogen percentage of human milk 
proteid, according to the total proteid of the mixture and the lactalbumin 
correspondingly increased. 

Cow's Milk as compared with Woman's Milk. — We may in concluding 
the subject of the chemistry of cow's milk summarize the principal points 
of difference between cow's milk and human milk in the following table : 



TABLE 40. 

Woman's milk directly from the 
breast. 

Reaction Amphoteric. (More alkaline 

than acid. ) 

Water 87 to 88 per cent. 

Mineral matter 0.20 per cent. 

Total solids 13 to 12 per cent. 

Fats 4.00 per cent, (relatively poor 

in fatty acid. ) 

Milk-sugar 7.00 per cent. 

Proteids 1.50 per cent. 

Caseinogen (Konig) 0.59 percent. 

Lactalbumin (Konig)... 1.23 per cent. 

Coagulable proteids Small proportionally. 

Coagulation of proteids by 

acids and salts With greater difficulty. Curds 

small and flocculent. 
Coagulation of proteids 

by rennet Does not coagulate regularly. 

Action of gastric juice . . Proteids precipitated but easily 

dissolved in excess of the gas- 
tric juice. 



Cow's milk as ordinarily received, 
about twenty-four hours old. 
Slightly acid. 

86 to 87 per cent. 

0. 70 per cent. 
14 to 13 per cent. 

4.00 percent. 

4.50 percent. 
3. 50 per cent. 
2.88 percent. 
0. 53 per cent. 
Large proportionally. 

With less difficulty. Curds 
large and tenacious. 

Coagulates readily. 
Proteids precipitated but 
dissolved less readily. 



BACTERIOLOGY OP COW'S MILK.— A few matters concerning 
the bacteriology of cow's milk can best be considered in connection with 



FEEDING. 181 

the subject of substitute feeding. Respecting this question Dr. J. A. Jef- 
fries very aptly remarks that u it is a curious fact that, while older people 
are chiefly fed on sterilized food, — that is, cooked food, — infants are fed on 
food peculiarly adapted by its composition and fluid state to offer a home 
for bacteria." 

It is manifestly very important to use a milk for modification which is 
as free as possible from bacteria. In the milk commonly used in cities the 
number of bacteria to the cubic centimetre amounts to a million or more. 
Ten thousand bacteria per cubic centimetre is considered the maximum 
for good milk. In -the year 1899 a daily examination of the milk pro- 
duced by one of the farms connected with the milk laboratory in Philadel- 
phia was made at the Pepper Laboratory. The average for 334 days was 
1530 bacteria per cubic centimetre ; and this number fell in the autumn 
and winter to 1150 to 1195 per cubic centimetre. These figures show 
how, with especial care at the farms, milk can be radically changed in re- 
gard to bacteriology. 

In some experiments made by Jeffries agar-agar cultures were made 
before and after the different fluids were sterilized, and the colonies of 
bacteria were counted. His results coincide with those of previous ex- 
perimenters, — namely, that steaming for fifteen minutes is sufficient to kill 
the developed bacteria, while a second steaming is necessary for complete 
sterilization. Out of one hundred and twenty lots of milk steamed but 
once, all but four or five showed distinct signs of change within a month, 
while the majority of those steamed twice did not change at all. 

Jeffries' s experiments also show that spores develop slowly, and, in- 
deed, rarely form in milk, which, as he says, is an excellent medium for 
growth, while spore-formation among bacteria, like seeding among higher 
plants, is a phenomenon of impaired growth. He also explains the pres- 
ervation of some of the milk steamed but once by the absence of any 
enduring spores from the start. In an article of very great interest and 
value to the practising physician, "On the Bacteria of the Alimentary 
Canal," Jeffries has reviewed, at my request, the work done by the various 
dacteriologists : 

" Miller, De Barry, and Escherich have shown that living bacteria are 
to be found in the stomachs of men and animals, and the former author 
has also clearly proved that bacteria can pass through the stomach into 
the intestines and live for a considerable time. ... Of the morphology 
and biology of the forms found in the stomach little is known. The field 
is a new T one, and the species have not been sufficiently described to en- 
able others to recognize them with certainty. Miller has found five kinds 
which give off carbonic dioxide and hydrogen gas, lactic, acetic, and 
butyric acids being formed. ... Of the flora of the intestines much more 
is known than of that of the stomach. The researches of Brieger, Vignal, 
Stahl, and Escherich have now proved that a large number of species may 
occur in the faeces. Brieger isolated two new T kinds : one a micrococcus, 



182 PEDIATRICS. 

which turns grape- or cane-sugar into ethyl alcohol, with a trace of acetic 
acid ; the other the well-known Brieger's bacillus. This species occurs in 
the faeces in vast numbers, ferments sugar, and decomposes albumins. 
Vignal isolated ten species from the faeces, six of these also being found in 
the mouth. Of these some produced acid fermentations and gas, but un- 
fortunately they were not sufficiently studied to show their effects on 
digestion. . . . Escherich studied especially the faeces of infants, and 
found a large number of kinds of bacilli, among them a small bacillus 
capable of converting milk-sugar into lactic acid, carbonic dioxide and 
hydrogen gas being evolved, either in the presence or absence of air, 
a facultative anaerobic species, his bacillus lactis aerogenes. Escherich 
established, by the examination of a large series of cases, the fact that the 
kinds occurring in the faeces vary with the food,— -that is, the intestinal 
contents. . . . Starting at birth with the sterile meconium, consisting of 
mucus, epithelium, and the like, infection by the mouth and rectum quickly 
occurs, and in a short time almost any form may be found, but chiefly 
such putrefying forms as proteus vulgaris. 

"With the suckling of the infant and the substitution of the refuse of 
the milk and secretion of the digestive tract for the meconium, a sharp 
transition occurs. Instead of the generally distributed forms causing de- 
composition, only two kinds are regularly found, bacillus lactis aerogenes 
and Brieger's bacillus ; the first chiefly in the upper parts of the intestine, 
the second in the lower parts. Passing on to the period of mixed diet, 
quite a number of forms appear, among them the streptococcus coli gracilis, 
the putrefying green fluorescing, a tetrad coccus, and several hinds of yeast. 
This brings us to the pith of the subject : Why are the flora so limited in 
the milk-eating infants and so diverse in others ? What drives the forms 
found in the meconium out ? That they can live there is clear, as shown 
by their presence the day before. Again, what prevents forms so common 
with meat diet from gaining a footing ? It is not the milk alone, for milk 
is an almost universal food for bacteria, and all the kinds found in the 
intestines thrive in it. 

" According to Escherich, the bacillus lactis aerogenes and the milk diet 
keep out the other forms. 

"Formerly," continues Jeffries, "even before the action of ferments 
and putrefactive processes were clearly understood, the significance of this 
question was seen. The chyme is a mass admirably adapted for putre- 
faction or fermentation, yet ordinarily but little of either occurs. It is an 
alkaline or, as in the milk-fed, acid mixture, rich in albumins, fats, and 
the starch group, amply provided with water and warmth. Such a mix- 
ture outside the body at an equal temperature would quickly decompose. 
It was generally held that some preservative action was exerted by the 
digestive juices ; Bidder's and Schmidt's dogs with biliary fistulae were 
supposed to explain the whole. These dogs, deprived of their bile, be- 
came emaciated, and suffered from diarrhoea and decomposition of the in- 



FEEDING. 183 

testinal contents. Thus it seemed clear that in the absence of the bile 
decomposition occurred, — that is, that the bile was a powerful germicide 
or germ-inhibitor. During the last few years, however, different results 
have been obtained in cases of biliary fistula. Rohmann's dogs did not 
suffer from diarrhoea or putrefaction in the intestines, hence it is clear that 
the bile is not the cause of prevention. The diarrhoea, if present, is due 
to the large amount of fat passed on to the lower intestines. 

" Maly and Emich ascribed value to the bile acids, especially the tauro- 
cholic, basing their results on crude methods ; and Lindenberger, really 
leaving the subject, attributed the action to the organic acids in combina- 
tion with the bile. 

- ; All this argument and belief in the decided germicidal action of the 
bile occurred in the face of the well-known fact that bile itself will de- 
compose. 

kt From a bacteriological stand-point, Miller has shown that a ten per 
cent, solution of bile, if anything, favors growth. Macfadyen has studied 
bile, bile salts, and bile acids in varying strengths. The only positive 
results were got with the acids ; these arrested the development of bac- 
teria if sufficiently strong, especially taurocholic acid. Neither acid had 
much effect, and least of all on the forms causing putrefaction. Proteus 
vulgaris was only arrested by a strength of from one to two per cent. 
The pathogenic forms were arrested by a much smaller quantity, from 
one to one-half per mille. 

" It is thus clear that other causes must be sought for. One of these 
is to be found in the lack of oxygen in the intestines, as pointed out by 
Escherich and strangely forgotten by others. There is certainly very 
little free oxygen in the chyme, if any ; not only is it scarce in the food at 
the start, but is taken up by the chemical changes during digestion, and 
also by the intestines. This clearly must be a potent factor, for the 
majority of bacteria require a fair supply. Accordingly, many bacteria 
are found in the faeces which will grow in the air, as shortly stated by 
Macfadyen, and the mass of those isolated in the air are able to grow 
without it. 

" This apparent contradiction, the absence of oxygen in the intestines, 
and the presence of both aerobic and anaerobic bacteria, is probably ex- 
plained by the ability of the aerobic kinds to draw oxygen from oxyhaem- 
oglobin. They thus breathe through the intestines, as it were, when in 
close contact with the walls, while the anaerobic kinds live in the mass 
of the chyme, and do not, so far as we know, reduce oxyhsemoglobin. 

" Escherich, though he points out the absence of oxygen, does not seem 
to give it full value, or rather forgets the subject in treating of the action 
of his lactic acid bacillus. As before stated, this form is regularly found 
in great numbers in the upper part of the intestines of milk-fed children, 
Here it converts a considerable part of the milk-sugar into lactic acid, and 
thus prevents the other forms from growing, — most forms being suscepti- 



184 PEDIATRICS. 

ble to an acid reaction, and especially to the organic acids. The action 
of salicylic acid is known to all, and recent experiments, of which Mac- 
fadyen's (the last) are the best, show acetic, butyric, and lactic acids to be 
efficient germ-inhibitors in strengths of from one to one-half mille accord- 
ing to the species. 

" In milk-fed infants another point is the comparative inability of bac- 
teria to attack casein, so that the bacteria are literally starved. 

"We may therefore conclude that the bile acids, lack of oxygen, lack 
of suitable albumins, and the presence of organic acids are the causes of 
immunity from the putrefying and fermenting kinds of bacteria to which 
we are exposed. Certain forms are probably limited by the lack of 
water, — that is, of a fluid state, — doing poorly if unable to swim freely 
about. It must not, however, be supposed that bacteria are scarce in the 
intestines ; on the contrary, they form a large part of the dry substance 
of the faeces. 

" The ferments act by the production of various acids, chiefly derived 
from the milk-sugar. In small amounts, as in the case of the bacillus 
lactis aerogenes, the acid seems to be of benefit, and certainly does no 
harm, as it regularly occurs in healthy breast-fed infants. In large 
amounts, however, it must tend to over-acidify the contents of the 
intestines and interfere with the action of the digestive fluids. 1 ' 

MILK - LABORATORIES AND PERCENTAGE FEEDING.— 
General Considerations. — When human milk that is suited to the indi- 
vidual infant cannot be obtained, or if obtained cannot be regulated by 
modification, it is desirable to substitute for it the combination of ele- 
ments which such a human milk represents. To accomplish this we must 
have materials which, while closely resembling the elements of normal 
human milk, are easily obtained. 

Physiological experiments on the mammary gland show that the 
albumin of the milk is not directly an exudation from the lymph-vessels 
supplying the mammary gland, but that it is actually modified in the 
gland itself. We thus see that the mammary gland, besides being an 
elaborator for infant nutrition, is also a modifier. This suggests to us 
that the modification of milk is not contrary to nature's method of pre- 
paring food for infants. Following, therefore, nature closely, we have 
learned that the proper modification of absolutely pure and fresh milk is 
the vital principle which should underlie our efforts to perfect a substitute 
food. 

The infant at the breast receives for its nutriment a fluid which is 
fresh, sterile, amphoteric, or faintly alkaline, which has a temperature of 
36.7°-37.8° C. (98°-100° F.), furnished in an amount proportionate to 
the age and size of the consumer. It is this fluid which we have to copy 
in every possible detail when we undertake to prepare a substitute food. 
We should also consider as foreign matter, to be carefully avoided, any 
element which we know is not to be found in the milk we are copying. 



FEEDING. 185 

The analyses of human milk teach us that there is a great capacity in 
different infants to assimilate a variety of proportions of the same nu- 
tritive elements. In all probability the infant needs a variety in its food 
somewhat to the same extent as does the adult. In order, therefore, to 
copy nature closely, we must have some means of preparing a food not 
only for the many but for the individual, and when introducing new 
methods for preparing a substitute food we must recognize the necessity 
of providing for many prescription possibilities. In this busy age of 
scientific rational medicine physicians all over the world demand, first,, 
means of saving time, and second, exact methods of work, which in 
themselves soon become time-savers. In every branch of our art the 
tendency is growing year by year to systematize the detailed and laborious 
work of the individual for the common practical use of the profession at 
large. The subject of substitute feeding should be reduced to a more 
exact system, and an effort should be made to rescue this important 
branch of pediatrics from the pretensions of the owners of proprietary 
foods and the hands of ignorant nurses. With this end in view, I have 
given my professional assistance to the establishment of a system of 
milk-laboratories where the materials used shall be clean, sterile, and 
exact in their percentages. These laboratories have been placed under 
the control of educated, intelligent men in whom we have the same confi- 
dence that we have conceded to the pharmacist, and we can write direc- 
tions for infants' foods and send them to these laboratories just as, in the 
treatment of disease, we write our prescriptions for the division of one 
drug or the combination of several. As the pharmacist has nothing to 
do with the various methods of treating disease, so the milk-modifier is 
simply required to carry out the directions and ideas of the physician. 
No special school of medicine need be represented. No special method 
of feeding need be undertaken. An opportunity has, however, for the 
first time in the history of medicine, been presented for the physician to 
carry out his own methods, and these methods for the first tiuie to be 
judged on a fair basis. In this way only can each clinical observer, when 
lacking in success, be sure that it is the fault of the food he is giving, and 
not because the food has varied from what he supposed he had ordered. 

In quite a number of cases rather gross changes in the percentages of 
the different elements of the milk may be sufficient for the range of the 
individual digestion and for the nutrition of the especial case, but it has 
been my experience with a very large number of infants whose vitality 
was low and whose malnutrition was excessive, to find that the lives of 
these infants could only be preserved by gradual and minute changes in 
the percentages and combinations of the milk-elements. We therefore 
cannot be too particular in assuring ourselves that we are using a milk- 
modification which is as precise as any knowledge up to the present time 
has made it possible to be. Even slight changes, therefore, in the percent- 
ages of the three important elements of milk of which we have most accu- 



186 PEDIATRICS. 

rate knowledge — namely, the fat, the sugar, and the proteids — are of real 
value in the management of the digestion and nutrition of the infant, and 
these changes are often necessary day hy day as well as month by month. 
With this fact impressed upon us, we can well see that no one mixture will 
in all cases prove successful, but that a great variety in the percentages of 
the different elements of the milk will be needed in substitute feeding just 
as they already exist in maternal feeding. This explains the diversity of 
results obtained in the past with the same food by different practitioners. 
Regarding the subject from this point of view, it is evident that there is no 
especial combination of percentages for the especial age of the infant, for 
the proper nutritive value of the food given to an individual infant must 
be adapted to that infant's special stage of development and to its special 
powers of digesting certain percentages and combinations of percentages. 
It has been frequently observed that an improper modification for the in- 
dividual may do much harm and may lead to something more than indi- 
gestion, — namely, to such diseases of nutrition as infantile atrophy, scor- 
butus, and rhachitis, — so that it is exceedingly important that the physician 
should understand the exact modification called for in each case as thor- 
oughly as he would the treatment of any disease in the individual. 

The means for prescribing a diversity in the elements of milk, accord- 
ing to the idiosyncrasy of the digestion we are dealing with, is supplied 
by a milk-laboratory equipped with special machinery and controlled by 
educated milk-modifiers. Purity of the original material is the first object 
to be attained. This material, milk, should be obtained from cows bred, 
fed, and cared for in the manner just described, and, in order to insure 
absolute uniformity in the methods, untiring vigilance must be used in the 
supervision of the farm, cows, and milk-house, and in the transportation 
of the milk from the farm to the laboratory. It is also necessary that the 
cows should be under the medical supervision of a skilled veterinary sur- 
geon. These are all questions which to my mind have been definitely 
decided, but which now need time and attention devoted to them to insure 
their being systematically carried out. As in all other advances which are 
made in practical medicine, so also in this one it is well to adopt at once 
a high standard of work and to demand everything that can in any way 
tend to perfection. We may not always be successful in carrying out all 
the details, but, until we are, perfection will not be reached. It must, 
then, be borne in mind and understood that each link of that chain is of 
vital importance, because, if broken, the value of the whole chain may be 
lost. One end of this chain is at the milk-farm. Starting in the stall of the 
cow it passes on to the milk-house, from the milk-house to the milk-labora- 
tory, and from the laboratory it should be carried unbroken and intact to 
the infant consumer. 

Apparatus for Feeding. — Human ingenuity has not yet been able to 
devise anything which approaches the perfection of nature's apparatus for 
feeding, and the best that we can do to offset this complex mechanism is 



FEEDING. 



187 



to adopt that which is exactly the reverse, — namely, an apparatus of abso- 
lute simplicity, — and thus combat the tendency to fermentation by pre- 
venting, through perfect cleanliness, the apparatus from becoming a source 
of fermentation. To accomplish this object the receptacle from which the 
infant is to be fed should be made of glass, in the form which will enable 
it to be most easily cleansed, and, as in the future the question of trans- 
portation will undoubtedly be a grave one, the receptacle should be such 
that it can be adapted to transit and not easily broken. For this purpose 
what are practically test-tubes fulfil these indications best. These tubes 
have open mouths, larger than those usually provided in the ordinary 
nursing-bottle, and, having no angles, are readily cleansed. The artificial 
receptacle is not self-regulating, and hence we must determine the amount 
of food in bulk which nature provides for the average infant at different 
ages, and from these average figures deduce the proper amount for the 



Fig 46 





Stomach from infant 5 days old ; capacity 25 c.c. 
(Natural size.) 



Glf 



cylinder, capacity 25 c.c. 
(Natural size.) 



especial infant. The feeding-tubes are graduated for the more important 
periods of growth, for the purpose of continually impressing upon the 
mother and nurse what the physician often has the opportunity of telling 
them only at the beginning of the nursing period, — namely, that the error 
is in giving too much food rather than too little, an error, also, which nat- 
urally results when, as is commonly the case, the usual eight-ounce 
nursing-bottle is provided as the receptacle at the very beginning of infan- 
tile life. 

I have found that I can easily convince most mothers of the mistaken 
zeal of nurses who advocate giving the young infant large amounts of food, 
by showing them the size of the infant's stomach at birth and comparing 



188 



PEDIATRICS. 



this small tube which corresponds to the stomach's capacity with an eight- 
ounce nursing-bottle. 

Nipples. — A nipple made of fine soft rubber adapted to the especial 
infant as to its size and the holes for the milk is substituted for the mater- 
nal nipple. These rubber nipples should be large enough to be turned 
inside out and carefully cleansed after each feeding. They should be 
boiled after being used, and kept in cold distilled water with a little soda 
in it. They should be renewed frequently, the oftener the better : pref- 
erably a new one should replace the old one three times a week. It will 
be found that the rubber nipple has to be adapted to the taste of the espe- 
cial infant, and that it often has to be changed as to its size, texture, and 
holes before the infant is satisfied with it and sucks satisfactorily from it. 

Intervals of Feeding. — The intervals between the feedings given below 
should also be adopted in substitute feeding, but the amount of food to 
be given now becomes a prominent feature in the division of the total 
amount of food which it is proper to give in the twenty-four hours, 
according to the age and development of the individual infant. 

Amount at Each Feeding. — The infant's weight and its gastric capacity 
quite frequently do not correspond. Yet there seems to be no doubt 
that the weight is a condition to which marked consideration should be 
given when we are attempting to determine so difficult a question as the 
proper amount of food to be given at each meal in the early months of life. 
The amount to be given at each feeding must be carefully regulated accord- 
ing to the gastric capacity. 

TABLE 41. 

General Rules for Feeding during the First Year. 
The day feedings are supposed to begin at 6 A.M. and to end at 10 P.M. 



Age. 


Intervals, 
hours. 


Number of 

Feedings in 

24 hours. 


Number of 

Night 
Feedings. 


Amount at each 
Feeding. 


Total Amount in 24 
hours. 










Cubic 




Cubic 












Centimetres. 


Ounces. 


Centim etres. 


Ounces. 


1 week .... 


2 


10 


1 


30 


1 


300 


10 


2 weeks . . . 


2 


10 


1 


45 


n 


450 


15 


4 weeks . . . 


2 


9 


1 


75 


2* 


675 


22£ 


6 weeks . . . 


2^ 


8 


1 


90 


3 


720 


24 


8 weeks . . . 


2* 


8 


1 


100 


3£ 


800 


26 


3 months. . 


2£ 


7 





120 


4 


840 


28 


4 months. . 


2* 


7 





135 


H 


945 


81$ 


5 months. . 


3 


6 





165 


H 


990 


33 


6 months. . 


3 


6 





175 


5f 


1050 


34£ 


7 months. . 


3 


6 





190 


6i 


1140 


37£ 


8 months. . 


3 


6 





210 


7 


1260 


42 


9 months. . 


3 


G 





210 


7 


1260 


42 - 


10 months. . 


3 


5 





255 


H 


1275 


42£ 


11 months. . 


3 


5 





265 


8| 


1325 


43f 


12 months . . 


3 


5 





270 


9 


1350 


45 



The above table shows how the intervals of feeding and the amount 
of food to be given should correspond to the gastric capacity at different 



FEEDING. 189 

periods of the first year. It is so important to avoid stretching so easily 
distensible an organ as the stomach that it is wiser to give too little rather 
than too much food in the early days of life, and then gradually increase 
the amount if the infant cries from hunger. 

The first month being the most critical period for the infant's nutrition, 
as it is the time when the equilibrium of its metabolism is being estab- 
lished and its chance for life is least, especial interest should be attached 
to the series of careful investigations made at the Children's Hospital in 
St. Petersburg by Ssnitkin to determine the amount of food which should 
be given in the first thirty days of life. As the result of these investiga- 
tions he deduces the rule, "the greater the weight the greater the gastric 
capacity." Ssnitkin' s general results show that one-one-hundredth of the 
initial weight should be taken as the figure with which to begin the computa- 
tion, and to this should be added one gramme for each day of life. 

Illustration of Ssnitkin' s rule to aid in adjusting the food to especially difficult cases in the 

first thirty days. 

Amount at each Feeding. 

Initial Weight. Early Days. At 15 Days. At 30 days. 

3000 grammes 30 grammes. 30 -f- 15 = 45 grammes. 30 -f- 30 = 60 grammes. 

(About 1 ounce. ) (About 1J ounces.) (About 2 ounces. ) 

4500 grammes 45 grammes. 45 -j- 15 = 60 grammes. 45 -j- 30 == 75 grammes. 

(About 1| ounces.) (About 2 ounces.) (About 2J ounces.) 

6000 grammes 60 grammes. 60 -f- 15 = 75 grammes. 60 -f- 30— 90 grammes. 

(About 2 ounces. ) (About 2 J ounces.) (About 3 ounces. ) 

It is wiser always to accomplish first the proper digestion of the food, 
even if there is no gain in weight, and then, when once the infant is 
digesting well, to increase the amount of the percentages of the different 
elements. At times when the infant is digesting well, and even gaining, 
it will suddenly cry so hard and with such evident hunger, that an imme- 
diate increase in the amount of its food is not only indicated but de- 
manded, no matter what its age or weight. In these cases the stomach 
has probably grown rapidly and out of its normal proportion to the age 
and size of the child, and a larger supply of food is what is needed. 

THE MILK-LABORATORY. — As milk-laboratories are now so well 
known, and have for some years been established all over the United 
States and in Canada and London, they need not be described in great 
detail. 

A milk-laboratory should be a place to which the milk should be de- 
livered from such farms and under such precautions as have already been 
described : it should be in a central locality, accessible to as many people 
as possible, and used exclusively to prepare ,from the prescriptions of 
physicians alone, any modification of milk which may be called for. 

As milk is one of the best means for the cultivation of bacteria, the 
laboratory should be situated in a healthy locality. It should be as free 
as possible from contaminating influences, should be kept absolutely clean, 
and every aseptic precaution against the harboring or development of 



190 PEDIATRICS. 

pathogenic organisms should be taken. To insure perfect work the great- 
est vigilance is needed in every department of such a laboratory. 

From the moment that the milk is delivered from the farm at a tem- 
perature of about 4.4° C. (40° F.) it should be watched over and cared 
for with scientific accuracy during the whole process of the modification 
which it undergoes in the laboratory. The milk-rooms should be cool 
and free from dust, and isolated, so far as possible, from other parts of the 
laboratory. 

There should also be an entirely separate room where the returned 
packages and all articles received from the homes of the consumer should 
be directly brought from the street or wagons, and where these articles 
can be immediately sterilized in apparatus reserved for this purpose. 

The modifying materials used in the laboratory should be carefully 
kept for use in glass vessels, and at a temperature of about 4.4° C. (40° 
F.), to prevent the growth of bacteria. The reason for this is that milk 
modified from materials free from bacteria is not only better for the infant 
than milk in which the bacteria have been destroyed by heat, but that 
there are certain toxins which cannot be destroyed by heat, and by their 
virulence may cause serious disturbance even after the most thorough 
sterilization has been carried out. 

In a carefully guarded milk-supply also it is seldom necessary to ever 
pasteurize a milk which is sent out from a well-equipped laboratory. On 
the other hand, modification has been found to fail entirely when applied 
to old milk, dirty milk, and to milk bacteriologically impure. 

A special room should be provided for the milk-modifiers who are to 
put up the mixtures required by each prescription. There should either 
be a room in the laboratory where the milk is separated by means of ma- 
chinery and where it can be tested and steamed, or this can be done in 
the milk-room at the farm. The office at the laboratory should be entirely 
separate from these work-rooms, so that customers coming to leave their 
orders should not go near the materials used for modification and thus 
possibly contaminate them. All odors should be excluded from the work- 
rooms, as they are absorbed by milk very quickly. It is hardly necessary 
to say that the employees of a laboratory, whether they be in the office 
or in the work-rooms, should be intelligent and interested in their work, 
and that the modifying clerks should be especially instructed in the neces- 
sity of absolute cleanliness, should be made to understand the dangers of 
sepsis and the importance of asepsis, together with a practical knowledge 
of how to guard against and exclude pathogenic organisms. 

Milk-Room. — The milk should be aerated and cooled to about 6.66 D 
C. (44° F.) at the farm, then packed in ice in such a way as to maintain 
its temperature during transportation below 7.22° C. (45° F.), and deliv- 
ered to the milk-room within a few hours of the time of milking. 

This milk, as a result of the especial manner in which the cows have 
been fed and cared for and the selection of them according to the proper 



FEEDING. 



191 



breed, may be said to have an almost uniform percentage of its elements. 
Even at those times of the year when the percentages of the different ele- 
ments of milk commonly vary from changes in the pasturage and in the 
habits and surroundings of the animals, the milk of these cows, which 
have their food supplied to them in stated rations at one time of the 
year as well as another, is not subject to the elemental variations which 
occur in the milk of ordinary cows. 

Separating-Room. — The milk can be separated either at the farm or 
in the laboratory in a room arranged and cared for in very much the 
same way as the milk-house at the farm. The walls are of white tile, 
and the ceilings are of material which can be washed and scrubbed. The 
floor is of asphalt, impenetrable to water, and is kept thoroughly moist- 
ened and free from every kind of dirt and dust. 

Ventilator. — In addition to the other precautions against pathogenic 
germs, the air of the separating-room is kept fresh and pure by means of 
a ventilator. This consists of a large steel fan, which revolves at the rate 
of two thousand times a minute, and by the force of 
its current carries away any flies or particles of dust Fig. 47. 

which may come within its reach. The air which 
comes into the separating-room, as well as into the 
milk-room and modifying-room, should be washed 
with sterile water. 

Separator. — The centrifugal separator revolves 
six thousand eight hundred times in a minute, and 
works with such searching effect on the milk that 
only a small percentage (0.13) of fat remains in the 
separated milk. 

The utility of the separator, however, does not 
consist wholly in its absolute withdrawal of the fat 
from the milk and in providing cream as fresh as to 
time as is the separated whole milk : it accomplishes 
two other very important results. First, by its great 
centrifugal force it separates from the cream and the centrifugal separator. 
separated milk any dirt or foreign matter of any 
kind which necessarily gets into every milk, and thus provides at once a 
practically clean milk, a most important result from a bacteriological point 
of view. 

Still. — A still for freshly preparing each day distilled water is part of 
the laboratory equipment. 

Modifying-Room. — In the modifying-room the milk is tested and the 
modification of the milk is completed. 

Babcock Fat-Tester. — To be doubly sure that the chemistry of the 
milk is what we suppose it to be from the uniform nature of the primal 
milk-supply, we take advantage of the knowledge which we have concern- 
ing the changes most likely to take place in certain elements of the milk. 




192 



PEDIATRICS. 



The percentage of the proteids, of the sugar, and of the mineral mat- 
ter in the milk of a herd of this kind, where uniformity in the feeding is 
the rule, is not apt to be appreciably affected. But the percentage of the 
fat in individual cows differs from day to day, and thus slightly affects the 
percentage of the fat in the milk of the herd. 

The fat, then, being the element by which we know whether each 
milking gives a uniform product, we test this element by means of what is 
called the " Babcock Fat-Tester. 1 ' Fig. 48 shows the Babcock machine. 



Fig. 48. 




Babcock fat-tester. 



To determine the percentage of fat, test-bottles containing the acidified 
milk are placed in a centrifugal machine, by the rapid revolution of 
which the fat is made to separate quickly and completely. The milk is 
acidified in order that the proteids, casein and fibrin, may be changed to 
soluble acid albumins, which offer less resistance to the rising and aggre- 
gation of the fat-globules. 

Approximately equal volumes of milk and commercial sulphuric acid 
of 1.82 specific gravity are mixed in a test-bottle with a long graduated 
neck. A pipette, delivering about 17.5 c.c. of milk, and a measuring 
cylinder for the acid, are used. The bottles are whirled for several min- 
utes at a temperature of 93° C. (200° F.) in a horizontal wheel making 
from seven to eight hundred revolutions per minute. This wheel is sur- 
rounded by a copper jacket, which may be filled with hot water for 
heating during the test. The separation of fat by gravity alone is not 
complete even when the bottles are left standing for several hours. By 
the centrifuge, however, a perfect separation is accomplished in a few 
minutes. If whirled at once, no heat need be applied, as that caused by 
the strong acid and milk is sufficient. After whirling, the bottles are 
filled to the neck with hot water, returned to the machine, and whirled 
for one or two minutes longer, after which they are filled with hot water 



FEEDING. 193 

to about the seven per cent, mark, and the machine is again turned for a 
short time, the temperature being kept up by means of a lamp or by 
filling the jacket with hot water. The fat separates and its percentage is 
noted while still liquid, preferably at about 65° C. (150° F.), the reading 
giving the percentage of fat directly without calculation and being easily 
taken to 0.1 per cent. 

This daily testing of the fat enables the modifier to preserve the accu- 
racy of his material, and to correct any variation in the percentage of the 
cream as it comes from the separator. 

Knowing the exact percentages contained in the cream and milk, the 
office clerk can, by a simple mathematical formula, give the required 
directions on the modifying clerk's formula for obtaining whatever per- 
centages of the other elements the physician may call for. 

Apparatus for the Transportation of Modified Milk. — Fig. 49 repre- 
sents the various forms of apparatus which are provided for feeding the 
infant in its home. 

Fig. 49. 




In the left of the picture is a basket holding eight tubes of a capacity of six ounces each. In front of 
this basket is a four-ounce tube in a wire stand. In the middle of the picture is a tin apparatus for 
warming the milk at the time of feeding. An alcohol lamp is shown beneath the warmer, and a tube 
of milk and a thermometer for testing the temperature of the milk are in the tin warmer. Next to and 
to the right of the tin warmer is a tube with a capacity of eight ounces. It is enclosed in a white worsted 
cozy, has the rubber nipple in place, and is supported in a wire stand. In the right of the picture is a 
basket containing six tubes with a capacity of eight ounces each. In front of this basket are an eight- 
ounce tube and a four-ounce tube. 

This apparatus is very simple and practical for transportation. A 
wicker basket, divided into a number of compartments corresponding to 
the number of feedings which are to be sent to the infant, has been 
found to be the most practical. These baskets with their tubes can be 
placed directly in the sterilizer, and are not harmed by the heat to which 
it is necessary to expose the food. 

This tin receptacle can be placed above an alcohol lamp ; the Avater in 
it is to be on a level with the height of the milk which is contained in the 
tube, and the tube is submerged in the water. It has been found neces- 
sary to take the temperature of the food by means of a thermometer 

13 



194 



PEDIATRICS. 



placed directly in the tube. No rule can be laid down by Avhich the tem- 
perature of the water-bath determines that of the milk, unless the tubes 
are of uniform thickness and the milk uniform in quantity and tempera- 
ture when placed in the bath. The thermometer must be washed in 
sterilized water with the greatest care, both before and after it is used. 
The food when given to the infant should have a temperature of from 
36.6° to 37.7° C. (98° to 100° F.). 

As in direct feeding from the breast the food which the infant receives 
has the same temperature at the end of the feeding as at the beginning, 
we should copy this provision of nature and not allow the temperature 
of the food to vary during the time it is being taken. To accomplish this 
end, a white worsted cozy can be used. The cozy is warmed at the same 
time that the milk is being heated, and the tube when placed in it is pre- 
vented from cooling. Thus the infant receives a food of unvarying tem- 
perature throughout the whole of the feeding. 

Fig. 50 represents an ice-box which can be used in hot weather, and 
has proved to be of great practical utility. It admirably serves the pur- 



Fig. 50. 




Ice-box, holding twelve tubes. Receptacle for ice in centre of box. Laboratory prescription-blank in 
front of box, and packing paper under end of open lid. 



poses of an express box and of a home refrigerator. The ice is packed in 
a metal compartment in the middle of the box, and the tubes are placed, 
each in its own compartment, around the sides of the ice-receptacle. 

Materials for the Modification of Milk. — The cream as well as the 
fat-free milk contains its own definite percentages of sugar, proteids, and 
mineral matter. The following analysis shows the percentages of the 
fat, sugar, and proteids in a laboratory sample of sixteen per cent, cream 
as compared with the fat-free milk : 







FEEDING. 














Fat. 


Sugar. 


Proteids. 


Cream 






16.00 
0.13 


4.05 
4.60 


3.20 


Fat-fre( 


i milk 




3.60 



195 



To provide the means for adjusting the percentages of the sugar 
which are called for, a carefully prepared twenty per cent, solution of 
milk-sugar and distilled water is used. The reaction of the food is 
adjusted by means of lime-water. 

In addition to the materials used for purely milk mixtures, other arti- 
cles of food, such as freshly prepared oats, barley, and wheat, can be 
obtained at the laboratory, and these can be prescribed by the physician 
in any combination or according to any stated percentage of fat, sugar, 
proteids, or starch which he may wish. By calculation also a whole milk 
can be used in place of the separated milk, and a gravity cream in place 
of a separated cream, if a few hours' notice is given by the physician who 
is prescribing the mixture. It is well that this latter statement should be 
noted, as physicians are so apt to think that only separated milk and 
cream are used at the laboratories, and that the food is always sterilized 
or is always made alkaline with lime-water. This is not so, and it should 
be thoroughly understood that the laboratories are ready to provide 
whatever the physician orders, and in whatever way he orders, and that 
they are not allowed to do anything else, either to prescribe, to change 
the prescription, or to sell a modified milk preparation without a physi- 
cian's prescription, — that is, the laboratory is merely an instrument in the 
hands of the physician, and is in no way responsible for the results 
obtained from the feeding, except so far as freshness of material and 
exactness of combination is concerned. The physician, on the contrary, 
can order his preparations to be delivered unheated or at any temperature, 
whether it be 65.5° C. (150° F.), 75° C. (167° F.), or 100° C. (212° F.) ; 
alkaline or not, as he pleases, and if alkaline, made so in any way he 
prefers to order, such as by lime-water or soda ; his fat percentages can 
be given him with gravity cream if he prefers it to separated cream, and 
his proteids with whole milk instead of separated milk ; also his sugar can 
be cane-sugar if he prefers it to milk-sugar. 

The physician, however, should appreciate that separated milk con- 
tains far less dirt and much fewer bacteria than whole milk, and that 
using gravity cream means a six or eight hours' older cream, and necessa- 
rily more bacteria than a quickly separated cream, which gives us as fresh 
a material for modification as the milk. I personally have never been 
able to satisfy myself that the emulsion of the fat was in any way dis- 
turbed by the separator, and my clinical experience, which has been large 
with both separated and unseparated milk and cream, has never shown 
that any harm came from using the former. 

With these modifying materials the modifying clerks combine each 
infant's food according to the prescription before them, and pour it into 
the glass tubes from which the infant is to nurse. These tubes, which 



196 PEDIATRICS. 

have been especially devised as the most practical for general use, are 
adapted both for transportation and for use as nursing-bottles, and are 
easily cleansed. 

There are two sets of clerks. One set is engaged in modifying the 
milk according to the prescriptions. As soon as the tubes are filled by 
the modifying clerks they are passed on to the stoppling clerks, who im- 
mediately seal them with aseptic non-absorbent cotton especially prepared 
for this purpose, and place them in baskets, the compartments of which 
are adapted to the number of feedings ordered for the special infant. The 
tubes are kept on tube-racks within easy reach of the modifying clerks. 
Each basket has its own label attached to it, with the address of the 
person to whom it is to be sent. 

The rule of absolute cleanliness is carried out in every possible detail, 
from the table on which the materials are combined to the dress and 
hands of the clerks. 

The milk is thus separated and recombined according to the prescrip- 
tions, stoppled, and placed in their respective baskets for transportation. 

Sterilization of the Milk. — The sterilizer is so arranged that the 
steam which passes through it can be regulated so as to produce any 
degree of heat required up to 100° C. (212° F.). This is accomplished 
by a regulator attached to the steam-pipe. The man in charge of the 
heating of the food, by keeping his hand on the regulator and his eye on 
the thermometer which is fitted to the sterilizer, can subject the baskets 
and the tubes in them to whatever degree of heat is ordered, and of 
course for the length of time required. 

The question whether milk should be boiled or steamed is one which 
is not of much significance, and can be settled according to the fancy of 
the individual practitioner, a greater or less destruction of the bacteria 
contained in the milk taking place according to the degree of heat to 
which it is submitted. My own experiments in comparing steamed 
with boiled milk show that the odor and taste of boiled milk are present 
when milk is steamed, but to a much less degree than in boiled milk ; 
also that while a thick scum is formed on milk boiled for twenty minutes, 
which is tenacious and does not disappear on shaking, only a very thin 
scum forms on milk steamed for twenty minutes, and that this is not 
tenacious and almost entirely disappears on shaking. 

After the food has been heated, the baskets are taken out of the 
sterilizer and placed in the cooling-tank, where the temperature of the 
food is reduced to 13.3° C. (38° F.). The baskets are then placed in the 
delivery- wagon, which conveys them to their various destinations. 

When the baskets are delivered at the homes of the consumers, the 
baskets and tubes of the previous day are returned to the laboratory. 
When they reach the laboratory they are taken directly from the street to 
the wash-room, which is entirely shut off from the rest of the laboratory. 

Wash-Room. — In the wash-room, in order to carry out absolutely the 



FEEDING. 



197 



aseptic precautions, the baskets and everything which has been returned 
to the laboratory are placed in a special sterilizer connected with the wash- 
room. The bottles, after being sterilized, are thoroughly washed in tubs, 
which are especially adapted for this purpose, in a solution of soda and 
water. All the tags and stoppers are destroyed after sterilization. The 
baskets are of woven willow, and are easily kept sterile. 

In this way, always guarding against possible infection of all kinds, 
the laboratory enables us to make use of the chemical and bacteriological 
knowledge which we have acquired in connection with the feeding of 
infants, and fulfils the requirements of that system of substitute feeding 
which up to the present time has proved to be the best. 

Principles of Prescription Writing in Percentage Feeding. — Let it be 
supposed that a modified milk is to be prescribed for an infant four 
months old with a normal digestion and of normal weight and general 
development. The regular prescription blank issued by the laboratory 
can be used, but, of course, a milk prescription can be written as one 
would write for a drug. 

The following is a sample prescription, in which the physician writes 
for a total proteid without reference to the relative proportions of casein- 
ogen and lactalbumin : 



g. Per Cent. 

Fat 4:00 

Milk-sugar 7;00 

Total proteid 1J50 

( a) Caseinogen j 

(b) Lactalbumin (whey proteid) .. . I 



Ordered for 
Date 



Number of feedings 7 

Amount of each feeding. . 135 c.c. (f^4£). 

Infant's age 4 months. 

Infant's weight 14 pounds. 

Alkalinity 5 per cent. 

Heat at 155° E. 



Signature. 



In regard to the question of the reaction, it can be left to the milk- 
modifier, as we leave to him the carrying out of other directions con- 
tained in the prescription. If the milk brought to the laboratory on the 
special day when we are sending our prescription has been produced from 
cows fed, as has been previously described, on sugar-beets, the milk may 
be already sufficiently alkaline for an infant's digestion when normal. If, 
on the contrary, the milk has its usual acid or amphoteric reaction, the 
milk-modifier will make it slightly alkaline, in accordance with the physi- 
cian's prescription and according as the milk of the special day has a greater 
or less acid reaction ; or, if so ordered, he will make the alkalinity corre- 
spond to five per cent., ten per cent., twenty per cent., or to any percentage 
desired. For this purpose lime-water should be used, as being the best 
material and as least likely to do harm. If, however, the infant's diges- 
tion is not normal and we wish to prescribe a precise amount of lime- 
water, we can do so by writing for whatever percentage we choose, as we 



198 PEDIATRICS. 

do for the other elements of the milk. In modifying the milk which comes 
from the farm connected with the laboratory, as a rule, one-twentieth 
part of lime-water (five per cent.) is sufficient to make the reaction corre- 
spond to that of normal human milk. Table 39, page 175, shows what 
the percentage of lime-water should be in order to obtain a greater or 
less degree of alkalinity. The hydrate of lime is said to be soluble to the 
extent of 1 part in 778 parts of water at a temperature of 15.5° C. (60° 
F.). This would make one ounce of lime-water to contain rather more 
than 0.03 gramme (J grain) of Ca0 2 H 2 , hydrate of lime. 

The milk from the farms connected with the laboratory has proved 
to be comparatively free from bacteria, and in most instances it is un- 
necessary to destroy the few bacteria which exist in it ; and as it is not 
harmful to the infant, it need not be exposed to heat. When, however, 
the milk has to be transported a long distance, or when the infant has 
a delicate digestion or is sick, it is often better to heat the milk to 68.3° 
C. (155° F.). This temperature is sufficient to kill those developed bac- 
teria which would be of any harm to the digestion of the infant, and at 
the same time is below 72° C. (161.6° F.), the point at which coagulation 
of the proteids is supposed to take place. We thus obtain a practically 
pure fresh milk, uncooked and sterile. We therefore write in our pre- 
scription 68.3° C. (155° F.). If the milk is to be sent an unusually long 
distance, if the weather is hot, or if the milk-supply has to last more than 
twenty-four hours, a higher degree of heating can be used, according to 
the wish of the prescriber. Thus, 100° C. (212° F.) is a temperature 
used for these purposes at the laboratory. When, again, we wish the 
milk to be absolutely sterilized, as may be the case when we are preparing 
it for an ocean voyage or for a trip across the continent, not only a high 
degree of heat, 100° C. (212° F.), but two or three heatings, with intervals 
of twenty-four hours, are necessary for this complete sterilization, and 
this can be called for in our prescription. The length of time during which 
the milk should be heated, as a rule, can be left to the judgment of the 
superintendent. Ten minutes is often sufficient to kill the developed bac- 
teria and to make this especially protected milk practically sterile. Expe- 
rience, however, has proved that during transportation the milk is often 
exposed to temperatures conducive to the further development of bac- 
teria, and that practically the bacteriological results which we obtain in 
the laboratory do not entirely hold when the milk is exposed to these 
varied conditions of transit. As a rule, therefore, from twenty to thirty 
minutes is the proper time to heat mixtures of modified milk sent from 
the laboratory. 

When the prescription is sent to the office the clerk copies it into a 
book, which records each day's feeding of each individual infant, and 
then translates the physician's prescription into such form as can be 
readily understood by the modifying clerks. Of course this form may 
vary in different parts of the world, according as the metric or the 



FEEDING. 199 

apothecary system is in use. In the work of the American laboratories, 
although the prescriptions are written by the physicians in the metric 
system, it has been found more convenient, when delivered to the 
patrons of the laboratory, to have the amounts expressed in ounces and 
drachms. The office clerk, after translating the metric percentages into 
ounces and drachms, copies it on to a blank called the modifying clerk's 
prescription. 

The prescription is then placed in the hands of the modifying clerk, 
who combines the different elements of the prescription by means of the 
elemental materials Avhich have been brought into the modifying-room 
from a different part of the laboratory. 

Practical Limits of Laboratory Modification. — I have requested 
physicians to write their prescriptions within certain limits as to the per- 
centages of the fat, sugar, and proteids, and to allow the mineral matter 
for the present to regulate itself. The limits which up to the present 
time the laboratory has found it necessary to place on the prescriptions 
for the milk-modifiers, and within which the modifying clerk is supposed 
to put up the prescriptions, are as shown in the following table : 

TABLE 42. 

Eat from 0.03 to 36.00 

Sugar from 0.87 to 20.00 

Proteids from 0.22 to 4.00 

There is not much doubt that in the future more and more exact re- 
sults will be obtained, representing definite percentages of still wider 
limits. The results obtained from combining the modifying materials used 
by the modifying clerks have so often been proved to be practically cor- 
rect, that we can assume that when we write a prescription we shall 
obtain in return a product which in its various elements comes within a 
fraction of one per cent. 

The following figures show the various combinations of different per- 
centages, which when written for can be supplied by the laboratories : 

TABLE 43. 

Low Fats. 

Eat 0.03 0.04 0.08 0.12-16 

Sugar 2.00 3.00 4-5.00 6.00-7.00 

Proteids 0. 75 1.00 2.00 3.00-4.00 

Low Sugars. 

Sugar 0.87 1.40 2.12 3.50-4.30 

Eat 2.00 3.00 3.50 4.00 

Proteids 0. 75 1.00 2.00 3.00-4.00 

Low Proteids. 

Proteids 0.22 0.34 0.45 0.53 

Eat 2.00 3.00 4.00 4.50 

Sugar 2.00 3.00 4.00-5.00 6.00-7.00 



200 



PEDIATRICS. 



The low fats show the lowest percentage of fat which can practically 
be used at the laboratory, and have been combined with various possible 
percentages of sugar and of proteids. The low sugars show, in like 
manner, the lowest percentages of the sugar which can be combined- with 
these various percentages of fat and proteids. Finally, the low proteids 
show the various combinations which can be obtained with the fats and 
sugars. 

The Use of Whey in Percentage Feeding. — Although at present our 
knowledge of the comparative elemental percentages of the total proteids 
in both human and cow's milk is inexact, yet we can at least arrive at 
approximate results, with much benefit to an infant with weak digestion, in 
our endeavor to make the relative proportion of the lactalbumin in cow's 
milk correspond to what is probably provided by nature for purposes of 
nutrition in the proteid of human milk. It is evident, on examining the 
analysis of the proteids of human milk, that for some good reason the 
caseinogen is small in amount in comparison with the lactalbumin. In 
cow's milk, on the contrary, the lactalbumin is small in amount in com- 
parison with the caseinogen. 

Thus, while in human milk the lactalbumin is about two-thirds (§) and 
the caseinogen about one-third (J) of the total proteids, in cow's milk the 
lactalbumin is only one-fifth (A) to four-fifths (|) caseinogen. (Konig.) 
We should, therefore, first determine the total proteid percentage and then 
calculate the amount of whey needed to obtain two-thirds (f ) lactalbumin 
and one-third (J) caseinogen. As with our present knowledge this is not 
practicable except in comparatively low proteid percentages, we should 
calculate to come as near these proportions as possible. 

If, therefore, we are writing a prescription which calls for a total pro- 
teid of 1 per cent., we should calculate to have 0.75 per cent, of lactal- 
bumin and 0.25 per cent, of caseinogen. A prescription calling for fat 
3 per cent., sugar 6 per cent., proteid 1 per cent., alkalinity 5 per cent., 
would be written as follows : 



R 

Fat 3 

Sugar 6 

Proteids (total) 1 



(a) Lactalbumin (whey proteid). . 
(&) Caseinogen 



Per Cent. 
00 

00 
00 

75 
25 



Number of feedings 9. 

Amount at each feeding. . 75 c.c. ( ^2J). 

Infant's age 3 weeks. 

Infant's weight 9 pounds. 

Alkalinity 5 per cent. 

Heat at 155° F. 



It is to be noted that although the total proteid percentage in the milk 
for an infant may be considerably increased, it is these higher percentages 
which are the most irrational in their nutritive values in the early months 
of infancy, if we hold to the rule that the caseinogen should be only one- 
third of the total proteids. This ratio of lactalbumin to caseinogen can 
be obtained if we are writing for a low proteid, as in the above preserip- 



FEEDING. 



201 



tion, or in a prescription calling for a total proteid percentage of 0.75, of 
which 0.25 per cent, shall be caseinogen and 0.50 per cent, lactalbumin. 
If, on the other hand, we write for a high total proteid, such as 3 per cent., 
the highest percentage of lactalbumin that can be obtained is 0.60, and 
the remaining 2.40 per cent, is caseinogen, which practically reverse our 
ratio, making the caseinogen considerably over two-thirds (f) and the 
lactalbumin considerably less than one- third (J). 

It can be said, however, that as the infant grows older its power to 
digest casein becomes proportionately greater, so that in the later months 
of infancy — the tenth, eleventh, and twelfth — its proteolytic function has 
become adapted to this change in the ratio of the caseinogen and lactal- 
bumin, so that the higher total proteids, such as 2.50, 3, and 3.50 per 
cent., with the relatively high caseinogen and low lactalbumin become the 
proper nutritive proportion for the infant. 

The point especially to be emphasized is that in the early months of 
life, which demand a low proteid percentage, we can by the use of w T hey 
obtain, in a modified milk, the same proportions of lactalbumin and 
caseinogen which we find in human breast-milk at a corresponding period 
of infancy. Furthermore, I have found by practical use of these mixtures 
in a large number of cases that it is often desirable to depart from the 
proportions of whey proteids and caseinogen found in human milk. After 
starting with a prescription calling for percentages of whey proteid 0.25 
and caseinogen 0.25, it is now my custom in cases of difficult proteid 
digestion to increase the whey proteids as rapidly as possible to 0.90 per 
cent., and then, maintaining this percentage, to increase the caseinogen 
0.25 per cent, from time to time and as rapidly as the digestion will 
permit, until it has been raised to 1.00 per cent. I then pass to the 
ordinary total proteid of 1.50, 1.75, or 2.00 per cent., according to the 
indications. A further consideration of the use of whey will be found 
on page 229. 

The prescriptions calling for definite proportions of casein and whey 
proteids which can now be filled at the laboratory are as follows : 

TABLE 44. 

Any percentage of fat from 1 to 4. 

Any percentage of sugar from 4 to 7. 

Any of the following combinations of whey proteids and caseinogen : 



f hey Proteids. 


Caseinogen. 


Whey Proteids. 


Caseinogen 


Per Cent. 


Per Cent. 


Per Cent. 


Per Cent. 


0.25 


0.25 


0.90 


.0.50 


0.50 


0.25 


0.90 


0.60 


0.75 


0.25 


0.90 


0.75 


0.75 


0.50 


0.90 


1.00 


0.90 


0.25 


0.75 


1.25 



Peptonization of Milk. — Peptonized milk is cow's milk with its pro- 
teids partially or entirely predigested by means of the extract of pancreas 



202 PEDIATRICS. 

and soda. There is no doubt that the proteids of cow's milk are at times 
a source of trouble to the infant's digestion, and that under certain cir- 
cumstances they can with great benefit be treated by predigesting them 
for a time, and allowing a stomach which otherwise digests well to rest 
and recover its entire digestive power. It is of use also where a decided 
idiosyncrasy of the individual precludes the digestion of these constituents 
of the milk. In many cases the indigestion is attributed to a lack of 
power to digest proteids at all, while in fact the stomach is simply rebel- 
ling against an amount of proteids above the standard percentage, or 
against some other constituent. It would seem that, for the average in- 
fant, this predigestion of the proteids is contrary to nature's teaching. 
There are certain natural functions which should be allowed to act as 
they do on human milk, and it seems irrational and contrary to the laws 
of physiology not to encourage all the functions to act naturally, instead 
of forestalling their action and allowing them to fall into disuse and thus 
to be weakened. The infant's stomach is intended to digest proteids, and 
not to have the proteids digested for it. Clinically, also, the use of pep- 
tonized milk supports this view, for, so far as I know, no very brilliant 
results have been obtained from its use, except when the infant's digestion 
has been in an abnormal condition and one which has called for some 
decided relief from the proteid elements of milk. Peptonized whole milk, 
therefore, as a food for young infants is one which consists of too large 
an amount of digested proteids, too little sugar, and a very large over- 
proportion of mineral matter. Peptonization of modified milk should 
only be given in cases in which it has been found that various combi- 
nations of the fat and sugar with very low percentages of the proteids 
have proved inefficient. 

When a peptonization of the proteids is prescribed, the clerk at the 
laboratory calculates the amount of peptonizing powder required for each 
feeding, and sends a number of powders corresponding to the number of 
feedings. 

The technique for the peptonization of milk is as follows : 

In a clean glass jar containing 4 ounces of cold distilled or boiled 
water dissolve 1 gramme (15 grains) of bicarbonate of soda and 0.25 
gramme (5 grains) of pancreatine (extractum pancreatis), to which add 12 
ounces of the milk. Set the jar in a vessel of water at a temperature of 
41.6° C. (107° P.) for from seven to ten minutes, or longer, according to 
the extent to which it is desired to carry the peptonizing process. Cool 
immediately, and keep on ice until used. 

To peptonize modified milk an amount of the powders should be used 
corresponding to the percentage of the proteids in the mixture, taking 
the standard of whole milk to be represented by four per cent, of the 
proteids. 

The Use of Cereals in Laboratory Feeding. — When a physician orders 
cereals to be prepared at the laboratory, he is enabled to obtain prepa- 



FEEDING. 203 

rations containing exact percentages of the constituents of any cereal 
food. 

In substitute feeding, the addition to modified cow's milk of starch in 
various forms is frequently recommended. 

This brings us to the consideration whether starch should be made a 
part of an infant's food. Physiologically, we know that during the first 
ten or twelve months of life the function of converting starch into sugar 
is in the process of development. It is true that a partial conversion of 
the starch can be performed at quite an early age, and, in exceptional 
cases, to a much greater extent than by the average infant. It is rational 
to suppose that when a function is being developed it should not be taxed 
with a trial of the use which will later be demanded of it. That is, a 
function develops more perfectly if its power is not exerted too early. 
With these facts before us, and simply recognizing that the best known 
food for infants, woman's milk, does not, under any circumstances, contain 
starch, I believe that starch should not form a part of the infant's food in 
the early months of its life. 

When, in the latter part of the first year, it is deemed best to give 
cereals, it is desirable not to give immediately a high percentage of starch 
in the mixture. We should not ignore the fact that the various cereals 
contain fat and proteids as well as starch, and that the percentage of 
sugar in the mixture will be raised by the converted starch. A gradual 
change should be made in the infant's food until its digestive capabilities 
have become adapted to the food values indicated for digestion and 
nutrition in the second year, such as are represented by a higher rate of 
fat, sugar, and proteids. It is well at this period to use an undiluted 
milk, preferably from Holstein cows, and to obtain the increased sugar 
ratio from the starch given plus the 4.50 per cent, of sugar in the milk. 
Any additional sugar that may be needed at this time may be given with 
the food in the form of cane-sugar, rather than milk-sugar. The starch 
can best be obtained from the preparations of oats, barley, and wheat, as 
described on pages 239 and 240. 

The Emulsion in Modified Milk. — As the question has arisen in the 
minds of some physicians as to whether it is wise to use a centrifugal 
cream in making a modification, the objection being that the centrifuge 
destroys the emulsion, the following photomicrograph (Fig. 51) of a drop 
of unmodified cow's milk is interesting to study. The analysis of this 
especial milk was as follows : 

Cow's Milk. 

Fat 4.04 

Sugar 4. 55 

Proteids 4. 15 

Mineral matter 0. 71 

Total solids 13.45 

Water 86. 55 

100.00 



204 



PEDIATRICS. 



Fig. 51. 




Unmodified cow's milk. 



Fig. 52. 




Cow's milk separated and recomposed. 



FEEDING. 



206 



Fig. 53. 




Human milk. 



Fig. 54. 




Modified cow's milk. 



206 PEDIATRICS. 

Fig. 52 represents a drop of cow's milk modified to correspond to the 
same analysis as in Fig. 51 ; and in examining the two drops it will be 
seen that the emulsion in the modified drop is quite as fine as, if not 
finer than, that in the unmodified. 

Fig. 53 represents a drop of human milk, and Fig. 54 a drop of cow's 
milk, modified so as to correspond to the percentages of the human milk, 
which were as follows : 

Human Milk. 

Fat 2.67 

Sugar 6.37 

Proteids 2.69 

Mineral matter 0. 15 

Total solids 11.88 

"Water 88.12 



100.00 



The emulsion in these two drops of milk seems to correspond very 
closely, and certainly does not warrant the assumption that the emulsion 
has been seriously interfered with by separation and recomposition. 

It has been noticed that in certain instances when a cream mixture is 
subjected to the jar dependent upon transportation and delivery for any 
considerable distance, a portion of the fat has a tendency to collect on the 
surface of the milk in globules. Experiments made by White and Ladd 
under my direction have shown that transportation alone was not suffi- 
cient to produce this disturbance in the emulsion, and that it did not 
depend alone upon the use of centrifugal cream. Centrifugal and gravity 
cream mixtures, after eight to eleven hours of transportation on several 
successive days at a temperature such as prevails in average October 
weather, showed essentially the same macroscopic and microscopic ap- 
pearances, and their emulsions were hardly to be distinguished from that 
of whole milk. Moreover, it was found possible to produce these globules 
in a modified milk by placing the bottles in a box, the interior of which 
was kept warm during transportation by means of a vessel containing hot 
water, which was renewed at intervals. My opinion, based on the result 
of these experiments, is that the globules are produced by a combination 
of motion of transit with heat, such as prevails in summer ; and I have 
not found the nutritive value of the milk to be at all interfered with in 
the exceptional cases in which the change occurs. 

ILLUSTRATIVE CASES OP PERCENTAGE FEEDING.— The 
following cases were fed under my direction at the milk-laboratory during* 
the first year of their lives, and merely illustrate the changes that would 
naturally be made in the food during this period in the life of a healthy 
infant. 

The first case was a male, born November 18, 1892. The table shows 
the record of its weight and food during its first year : 



FEEDING. 



207 



TABLE 45. 

Showing Management of the Food and Increase in Weight of a Healthy Infant during 
First Fifty-Two Weeks of its Life. 



the 





Weeks 








Amount 


Percentages of Pood. 




Date. 


of 


* Weight. 




at each 










Life. 








Feeding. 


Fat. 


Sugar. 


Proteids. 


Lime-Water. 








Grams. 


Lbs. 


Oz. 


C.c. 


Oz. 












November 18 


1 
2 
3 


3752 


8 


6 


30 


1 


2.00 


6.00 


1.00 


5.00 
















3.00 


6.00 


1.00 








4 








"45 


' 1* 














5 

6 








75 
90 


2i 

3 


4.00 


7.00 


1.00 


10.00 




December 23 


'4284* 


" 9 


' 9 






t 

8 


















5.00 




January 13 


9 
10 
11 


6944' 


' 15 


' 8 


'ios 


' H 




































12 
























13 
14 
15 








120 
135 


4 

4J 


4.00 


7.00 


2.00 






February 17 


*6048' 


' 13 


7 


PR 




16 

























17 




















1— I 


March 17 


18 
19 
20 
21 
22 


6748 


15 


1 


150 


5 










O 



April 21 


23 


7308 


16 


5 


165 


5£ 










53 




24 






















25 




















O 




26 




















3 


May 18 


27 

28 


7504 


16 


12 


180 


6 


4.00 


7.00 


2.50 




+3 




O 




29 




















fan 

3 




30 




















2 




31 




















£ 


June 22 


32 
33 


7840 


17 


8 


210 


7 










1-3 









34 
35 












4.00 


7.00 


3.00 


12.50 




36 




















O 
O 




37 












4.00 


7.00 


2.50 




fr 




38 






... 






3.50 


6.50 


1.50 


10.00 






39 








180 


"e" 


4.00 


7.00 


2.00 


5.00 




August 17 


40 
41 
42 


'8820* 


" 19 


11 


225 


n 








10.00 
12.50 


























43 










... 


4.66 


" e'66" 


'" 2.5*6' 


10.00 






44 












4.00 


5.00 


3.00 


5.00 






45 
























46 
























47 












Wh 


ole mi 


Ik. 








48 
























49 












¥h 


ole mi 


Ik and 


oat-jelly. 






50 
























51 






















November 9 


52 


9870 


22 



















The grammes in the third column have been reduced to pounds and ounces on the basis 
of twenty-eight grammes to the ounce, and the fractions of the ounce have been disregarded. 



208 



PEDIATRICS. 



The next case was a female, born November 1, 1892. The chart 

shows the line of growth in its weight from birth to the fifty-second week 

of its life : , 

CHAET 2. 

























Wt 


igl 


< a 


Bt 


r*A 


3,1 


?0< 


7m 


mm 


es 


















1 
1 


Date of Birth JVov.lst. 


8 

o 


•to 

Or 


V 

o 
o 


c 


8 


to 
o 


cri 

o 


til 

o 


pi 


to 


o 
o 


--> 
c: 


s 


to 

o 


o 


Si 

c 


8 

c 


to 

CJI 

o 


o 

o 


en 

C 


CO 

8 

o 


c 


o 
o 


Ul 

c 


© 

s 


to 
© 


g 

© 


CI 

© 


§1 


Actual Weight 


3 


Gram's 


H 


o 




























































1 


3,180 


7 


1 


Nov 


1 




























































2 


3,180 


7 


1 


rt 


8 




























































3 


3.180 


7 


1 


'• 


15 




























































4 


3,430 


7 


10 


" 


22 
























































5 


3,520 


7 


14 


•' 


29 




























































6 


3,730 


8 


5 


Dec. 


6 
























































7 


3,980 


8 


14 


» 


13 




























































8 


4,160 


9 


4 


n 


20 




























































9 


4,340 


9 


10 


" 


27 














\J 












































10 


4,590 


10 


4 


Jan. 


3 














> 














































11 


4,870 


10 


14 


•' 


10 




























































12 


5.060 


11 


4 


» 


17 




























































13 


5,270 


11 


12 


» 


24 




























































14 


5,560 


12 


6 


" 


31 




























































15 


5,870 


13 


1 


Tec | 7 




























































16 


6,070 


13 


8 


- |14 




























































17 


6,300 


14 


1 


" 


21 


























































18 


6,370 


14 


4 


" 


oB 


























































19 


6,510 


14 


8 


Mar 


7 




























































20 


6,650 


14 


13 




14 




























































21 


6,920 


15 


7 


" 


21 




























































22 


6,980 


15 


9 


" 


28 




























































23 


7.150 


15 


15 


Apr. 


4 


























































24 


7,240 


16 


2 


« 


11 




























































25 


7,560 


16 


14 


"' 


18 




























































26 


7,600 


16 


15 


•• 


25 




























































27 


7,300 


17 


6 


Hay 


2 




























































28 


7,730 


17 


4 


» 


9 




























































29 


7,840 


17 


8 


» 


16 




























































30 


8,070 


18 





» 


23 




























































31 


8,160 


18 


3 


" 


30 




























































32 


8,190 


18 


4 


June 


6 




























































33 


8,490 


18 


15 


- 


13 




























































34 


8,470 


18 


14 


» 


20 




























































35 


8,700 


19 


6 


» 


27 
















































^ 












36 


8.762 


19 


8 


July 


4 
















































\ 












37 


8,824 


19 


11 


" 


11 
















































\ 










• 


33 


8,950 


19 


14 


" 


13 




























































39 


8,970 


20 





" 


25 
























































40 


8,980 


20 


1 


Aug. 


1 




























































41 


9,060 


20 


4 


'■> 


8 




























































42 


9.140 


20 


6 


>' 


15 




























































43 


9,340 


20 


13 


" 


22 




























































44 


9.170 


20 


8 


" 


29 




























































45 


9.290 


20 


12 


Sep. 


5 


























































46 


9,340 


20 


13 


" 


12 




























































47 


9,470 


21 


2 




19 


























































48 


9.640 


21 


9 


" 


26 




























































49 


9,630 


21 


8 


Oct. 


3 




























































50 


9,740 


21 


10 


" 


10 




























































51 


9,870 


22 





" 


17 




























































52 


9,890 


22 


1 


" 


24 


-a 


-3 


CO 


CO 


CO 


CO 


o 


o 


£ 


E 


K 


CO 


Lo- 


CO 


-f 


£ 


Ol 


CD 


s 




5 


CO 


CO 


to 


CO 

o 


CO 


to 


to 


C' 














c 


CO 


o 


CO 


o 


CO 


o 


CO 


o 


CO 


o 


co 


Ol 


K 


on 


CO 


o 


CO 


CO 


Ol 


-p. 


■o 


a> 


CO 


to 


£ 


41. 


CO 


5* 


. 


31 


eetht 


it 11 


Mi 


nths 


























Wt 


i^fif a 




W/t 


r* 


OW) 


•J* 


JO 


un< 


' 































FEEDING. 



209 



The following table records the quantity and quality of this infant's 
food during the first year : 

TABLE 46. 

Showing Management of the Food and Increase of Weight of a Healthy Infant during the 
First Fifty-Two Weeks of its Life. 



Date. 



November 1 . 
November 8 . 
November 15 
November 22 
November 29 
December 6. . 
"December 13. 
December 20. 
December 27. 
January 3 . . . 
January 10 . . 
January 17 . . 
January 24 . . 
January 31 . . 
February 7 . . 
February 14 . 
February 21 . 
February 28 . 

March 7 

March 14. . . . 
March 21 ... . 

March 28 

April 4. . . . . 

April 11 

April 18 

April 25 

May 2 

May 9 

May 16 

May 23 

May 30 

June 6 

June 13 

June 20 

June 27 

July 4 

July 11 .... 

July 18 

July 25 .... . 
August 1 . . . . 
August 8. . . . 
August 15. . . 
August 22. . . 
August 29. . . 
September 5 . 
September 12 
September 19 
September 26 
October 3 . . . 
October 10 . . 
October 17.. 
October 24 . . 



Weeks 

of 
Life. 



1 
2 
3 
4 
5 
6 
7 
8 
9 

10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
29 
30 
31 
32 
33 
34 
35 
36 
37 
38 
39 
40 
41 
42 
43 
44 
45 
46 
47 
48 
49 
50 
51 
52 



Weight. 



Gra'otis. 
3180 
3180 
3180 
3430 
3520 
3730 
3980 
4160 
4340 
4590 
4870 
5060 
5270 
5560 
5870 
6070 
6300 
6370 
6510 
6650 
6920 



7150 
7240 
7560 
7600 
7800 
7730 
7840 
8070 
8160 
8190 
8490 
8470 
8700 
8762 
8824 
8950 
8970 
8980 
9060 
9140 
9340 
9170 
9290 
9340 
9470 
9640 
9630 
9740 
9870 
9890 



Lbs. 

7 
7 
7 
7 
7 



10 
10 

11 
11 

12 
13 
13 
14 
14 
14 
14 
15 
15 
15 
16 
16 
16 
17 
17 
17 
18 
18 
18 
18 
18 
19 
19 
19 
19 
20 
20 
20 
20 
20 
20 
20 
20 
21 
21 
21 
21 
22 
22 



Amount 
at each 
Feeding. 



C.c. 

60 
60 
90 

75 



90 

105 



120 
135 



150 



180 



195 



Oz. 

2 
2 
3 



H 



Peecentages of Food. 



Fat. 



2.00 
4.00 
4.00 
3.00 
3.00 
3.00 
4.00 
4.00 
4.00 



4.00 



4.00 



4.00 

Wh 
Wh 



Sugar. 



5.00 
7.00 
7.00 
7.00 
6.00 
7.00 
7.00 
7.00 
7.00 



7.00 



7.00 



6.00 
ole mi 
ole mi 



Proteids. 



Lime-Water. 



1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.25 
1.50 



2.00 



2.50 



3.00 
Ik. 
Ik and 



5.00 



10.00 
5.00 



12.50 

10.00 

5.00 



oat-jelly, 



The grammes in the third column have been reduced to pounds and ounces on the basis 
of twenty-eight grammes to the ounce, and the fractions of the ounce have been disregarded. 

14 



210 PEDIATRICS. 

The following cases have a practical bearing on the method of substi- 
tute feeding by means of milk laboratories. 

The first illustrates how important it is to be able to vary the percent- 
ages of the different elements of the milk, and to know that we are 
obtaining these variations exactly as they are ordered. 

An infant was being nursed by its mother, who was healthy, and who had an 
abundance of breast-milk. Their summer home was by the sea-side, in a healthy 
situation, and the infant was surrounded with everything that could be desired for 
perfect hygiene. The infant during the first two months of its life nursed well, thrived, 
and was perfectly quiescent in its daily life. When it was three months old, the mother 
was very much worried by some family matters and did not take much exercise. The 
infant now began to have colic, and, although it gained in weight, it was very restless 
and cried continuously. An analysis of the mother's milk at this time gave the follow- 
ing result : 

Fat 2.69 

Sugar 6.15 

Proteids 3. 71 

Mineral matter 0. 17 

Total solids 12.72 

Water 87.28 

100.00 

The indications for treatment were, of course, to lessen the amount of mental dis- 
turbance in the mother and to make her exercise more. The mother having followed 
these directions, the symptoms in the infant soon became less severe. After a few days, 
however, the unfavorable symptoms returned, and it was found that the mother had 
not been exercising and was again mentally disturbed. As it seemed impossible to 
regulate the function of the mammary gland under these circumstances, it was decided 
to feed the infant from the milk-laboratory. The following prescription was ordered : 

Prescription 3. 

R Fat 3.50 

Sugar 6. 50 

Proteids 1.00 

Keaction Slightly alkaline. 

Heated to 75° C. (167° F.). 

Eight tubes, each holding 90 c.c. (3 ounces) . 

The infant digested this food perfectly, had no colic, and again became tranquil. 
As, however, it only made a slight gain in weight during the first two or three weeks 
of this substitute feeding I changed the prescription to the following one : 

Prescription 4. 

R Fat 4.00 

Sugar 7.00 

Proteids 1.50 

On taking this food the infant began to make regular gains in weight, and con- 
tinued to thrive until it was four months old, when it was brought back to its city 
home, where it was subjected to many of the annoyances which are so frequently seen, 
and which, although somewhat disastrous to the infant, tend to advance our knowledge 
of substitute feeding. The infant was surrounded with too much excitement, and was 



FEEDING. 211 

exposed to unnecessary changes of temperature in its home. During the process of 
removal from the sea-side to the city it caught a slight cold, and had intestinal symp- 
toms characterized by loose discharges from the bowels and undigested food. This 
condition was easily obviated in a few days by simply changing the prescription at the 
laboratory to the following one : 

Prescription 5. 

R Fat 2.50 

Sugar 5. 50 

Proteids 1.00 

Lime-water 10.00 

Under this treatment the food was again fairly well digested, the discharges 
lessened in frequency, and were of a better character. The infant, however, during 
this sickness had lost over 224 grammes (about } pound) in weight. 

At this juncture the grandmother of the infant so influenced the mother that she 
insisted upon having a wet-nurse procured at once. Although I did not approve of 
this change, the family were so urgent in their demands for a wet-nurse that I procured 
one for them. This wet-nurse was nursing her own infant and another infant at the 
Infants' Hospital. Both infants were thriving in every way. An analysis of this wet- 
nurse's milk gave the following results : 

Pat 2.92 

Sugar 6.20 

Proteids 4.62 

Mineral matter 0. 16 

Total solids 13.90 

Water 86. 10 



100.00 



The milk for this analysis was taken from the middle of the nursing. The per- 
centage of proteids was so high that I did not dare to allow the foster-infant to be put 
to the breast at once. I therefore endeavored to regulate the percentages of the elements 
of the wet-nurse's milk in the usual way. At the end of two days another analysis of 
her milk was made, with the following result : 

Pat 3.39 

Sugar 5. 95 

Proteids 4. 78 

Mineral matter 0.21 

Total solids 14.33 

Water 85.67 



100.00 



The extraordinarily high percentage of proteids in this analysis made me abso- 
lutely refuse to allow the foster-infant to begin with its nursing from the wet-nurse. 
The family, however, were very impatient, and argued that, as the other two infants 
were gaining in weight, digesting well, and looking remarkably ruddy, it must be a 
good milk which they were receiving from the wet-nurse. 

Two days later, although the foster-infant was decidedly improving on the substitute 
food from the laboratory, it happened to lose 30 grammes (about 1 ounce) in weight, 
and the family then insisted that this wet-nurse should be tried. Another analysis of 
the wet-nurse's milk was then made, and showed that the percentage of the proteids 
had been reduced to between 3 and 4. 



212 PEDIATRICS. 

I had already endeavored to find other wet-nurses whose milk would better corre- 
spond to what the infant needed, but was unsuccessful in obtaining any the analysis of 
whose milk showed the percentage of the proteids to be below 3. 

The analyses of the milk of two of these wet-nurses were as follows : 

Fat 3.88 

Sugar 6. 55 

Proteids 3.14 

Mineral matter 0. 14 

Total solids 13. 71 

Water 86.29 

100.00 

Pat 3.39 

Sugar 4. 50 

Proteids 4.70 

Mineral matter 0. 18 

Total solids 12.77 

Water 87.23 

100.00 

The first wet-nurse was then brought to the foster-infant's home, and the infant was 
put to the breast. It absolutely refused to take the breast for twelve hours, although it 
was crying with hunger. Finally it was induced to nurse, but immediately after the 
nursing had an attack of colic. These attacks of colic were moderately severe, and 
occurred after each nursing. The infant, soon appeared to like the milk and took it 
eagerly at the regular nursing intervals. In twenty-four hours from the time when the 
infant began to nurse its bowels were again affected. The number of discharges became 
frequent, and the milk evidently was not being digested well. These conditions lasted 
for several days, when it was found that the infant had lost over 480 grammes (about 1 
pound) in weight. As the severity of the colic was increasing, and as the infant had 
lost its color, the mother agreed to have the feeding by the wet-nurse discontinued. I 
then wrote the following prescription to be put up at the laboratory : 

Prescription 6. 

R Pat 2.00 

Sugar 5.00 

Proteids 1.00 

Lime-water 10.00 

To be heated to 75° C. (167° P.). 

This mixture was given to the infant. In twenty-four hours the number of dis- 
charges from the bowels grew less, and in a few days became almost normal. It began 
to gain in weight, and though seeming very hungry, looked better and ceased to have 
colic. 

The prescription was then changed to the following one : 

Prescription 7. 

R Fat , 3.00 

Sugar 6.00 

Proteids 1.00 

Lime-water 5.00 

On taking this food the infant began to make regular gains in weight, but still 
seemed hungry, so that at the end of another week the prescription was changed to the 
following one : 



FEEDING. 213 

Prescription 8. 

R Pat 4.00 

Sugar 7.00 

Proteids 1.50 

The infant now improved steadily. It made the normal average daily gains in 
weight, and soon recovered its color and former strength. From this time it continued 
to thrive. 

This case is interesting in many ways. It was very evident that a per- 
centage of proteids over 3 was more than this especial infant could digest. 
It therefore had to be weaned from its mother. The wet-nurse's milk, 
which was agreeing perfectly with her own infant and with another infant 
which she was nursing at the hospital, had a percentage of proteids be- 
tween 3 and 4. As I knew from my experience with the mother's milk 
that this high percentage of proteids would not agree with the infant, I 
was not surprised to find that, instead of agreeing with it, it made it sick. 
This case substantiates the statement that, while there are many varieties 
of good milk, there are also many infants who cannot thrive on them all, 
but only upon such as suit their individual digestive powers. 

It is interesting also to record in this case that as the infant grew older, 
it was found that the percentage of the proteids could be increased in its 
food without harming its digestion, and that by the time it was eight 
months old it was having in its food percentages of proteids between 3 
and 4, the very percentages which caused such serious digestive disturb- 
ance when it was younger. When it was ten months old it was able to 
digest 4 per cent, of proteids in its food. 

This case as a whole so well illustrates the use of the milk-laboratory 
that it is hardly worth while to multiply instances of its value. I believe 
that by the establishment of these laboratories a new era has been entered 
upon in the province of infant feeding, and one which will enable us to 
produce results which have never before been obtained. 1 

The following prescriptions which I have sent to the laboratory at dif- 
ferent times will give you a very fair idea of the simplicity and precision 
of substitute feeding. 

Prescription 9. 

A girl 6 years old ; duodenal jaundice [functional). 

R Pat 0. 50 

Milk-sugar 6.00 

Proteids 3.00 

Lime-water 10.00 

12 tubes, each 4 ounces. 

1 The first laboratory for the exact modification of milk that has been established in the 
world was opened to the public in 1891 in Boston, under the name of the Walker-Gordon 
Laboratory. The development of the system of modification in percentages and the estab- 
lishment of this as well as of eighteen other laboratories in different parts of the country 
and in London, which now represent the Walker-Gordon Company, was accomplished by 
the joint efforts pf Mr. G. E. Gordon, Mr. G. H. Walker, and Mr. J. H. Waterhouse. 



214 PEDIATRICS. 

Prescription 10. 
A boy 6 weeks old ; healthy. 

R Fat 3.00 

Milk-sugar 7.00 

Proteids 1.25 

Eeaction Slightly alkaline. 

Heated to 75° C. (167° F.). 

12 tubes, each 2 ounces. 

Prescription 11. 

A boy 6 months old ; healthy. 

R Fat 4.00 

Sugar 7.00 

Proteids 2.00 

Eeaction Slightly alkaline. 

Heated to 75° C. (167° P. ). 

8 tubes, each 6 ounces. 

Prescription 12. 

A girl 4 months old ; proteid digestion weak. 

R Fat 4.00 

Sugar 7.00 

Proteids 0.75 

Lime-water „ 5. 00 

Heated to 75° C. (167° F.). 

8 tubes, each 4 ounces. 

Prescription 13. 

A boy 6 months old ; sugar digestion weak. 

R Fat 3.00 

Sugar 4.00 

Proteids 2.00 

Lime-water ; 5.00 

Heated to - 75° C. (167° F.). 

8 tubes, each 6 ounces. 

Prescription 14. 

A girl 4 months old ; summer diarrhoea. Food has to be sent to a distant town by express. 

R Fat 2.50 

Sugar 6.00 

Proteids 0.50 

At time of each feeding add lime-water £ ounce. 

Heated to 100° C. (212° F. ). 

20 tubes, each 3J ounces. 

The lime-water had to be introduced at each feeding on account of 
the 100° C. (212° F.) heating, necessitated by the hot weather and the 
distance to be sent. If the lime-water had been introduced at the labora- 
tory and heated to 100° C. (212° F.) with the food, a reaction would have 
taken place between the lime and the sugar, and the mixture would have 
turned brown and have had a peculiar taste. 

Feeding of Average Infants born at Term. — When an infant is born 
at term, is of normal development and weight, and is healthy, I am in the 
habit of regulating the quantity of its food according to the table on page 
188. The quality of the food with which I usually begin is as shown in 
the following prescriptions. These percentages, however, are intended 
only to be provisional until the proper amount for the individual has 



FEEDING. 215 

been ascertained. When these prescriptions are used the infant is sup- 
posed to be digesting well and gaining in weight progressively. 

Prescription 15. 

For the first twenty-four to thirty-six hours of life. 
R Milk-sugar, five-per-cent. solution, in sterilized distilled water. 

Prescription 16. 
First week. 

R Fat 2.00 per cent. 

Milk-sugar 5.00 per cent. 

Total proteids 0. 50 per cent. 

q j Whey proteids 0. 50 per cent. 

I Caseinogen 0. 25 per cent. 

Alkalinity 5.00 per cent. 

Heated to 08.3° C. (155° F.). 

Prescription 17. 
Second week. 

E Fat. 2.50 per cent. 

Milk-sugar 5. 50 per cent. 

Total proteids 0. 75 per cent. 

q f Whey proteids 0. 75 per cent. 

1 Caseinogen 0. 25 per cent. 

Alkalinity '. 5.00 per cent. 

Heated to 68.3° C. (155° F.). 

Prescription 18. 
Third week. 

R Fat 3.00 per cent. 

Milk-sugar 6.00 per cent. 

Total proteids 1.00 per cent. 

~ f Whey proteids 0. 90 per cent. 

I Caseinogen 0. 50 per cent. 

Alkalinity 5.00 per cent. 

Heated to 68.3° C. (155° F.). 

Prescription 19. 
Four to six weeks. 

R Fat 3.50 per cent. 

Milk-sugar 6. 50 per cent. 

Total proteids 1.00 per cent. 

Q r f Whey proteids 0. 90 per cent. 

I Caseinogen 0. 75 per cent. 

Alkalinity 5. 00 per cent. 

Heated to 68.3° C. (155° F.). 

Prescription 20. 
Six to eight weeks. 

R Fat 4.00 per cent. 

Milk-sugar 7. 00 per cent. 

Total proteids , 1.25 per cent. 

q f Whey proteids 0. 90 per cent. 

I Caseinogen 1.00 per cent. 

Alkalinity 5.00 per cent. 

Heated to 68.3° C. (155° F.) 

Prescription 21. 
Two to four months. 

R Fat 4.00 per cent. 

Milk-sugar 7.00 per cent. 

Total proteids 1.50 per cent. 

Alkalinity 5.00 per cent. 

Heated to 68.3° C. (^155° F.). 



216 PEDIATRICS. 

Prescription 22. 
Four to six months. 

R Fat 4.00 per cent. 

Milk-sugar 7.00 per cent. 

Total proteids 2.00 per cent. 

Alkalinity „ 5.00 per cent. 

Heated to 68.3° C. (155° F.)- 

Prescription 23. 

Six to nine months. 

R Fat 4.00 per cent. 

Milk-sugar , 7.00 per cent. 

Total proteids 2. 50 per cent. 

Alkalinity 5.00 per cent. 

Heated to 68.3° C. (155° P.). 

Prescription 24. 
Nine to ten months. 

R Fat 4.00 per cent. 

Milk-sugar 7.00 per cent. 

Total proteids 3.00 per cent. 

Alkalinity „ 5.00 per cent. 

Heated to 68.3° C. (155° F.).. 

Prescription 25. 
Ten to ten and one-half months. 

R Fat 4.00 per cent. 

Milk-sugar , 5.00 per cent. 

Total proteids 3. 25 per cent. 

Alkalinity 5.00 per cent. 

Heated to 68.3° C. (155° F.). 

Prescription 26. 
Ten and one-half to eleven months. 

R Fat 4.00 per cent. 

Milk-sugar 4. 50 per cent. 

Total proteids 3. 50 per cent. 

Alkalinity 5.00 per cent. 

Heated to 68.3° C. (155° F. ). 

Prescription 27. 

Eleven to eleven and one-half months. 

R Unmodified cow's milk and cereals. 

At about the tenth or eleventh month I usually begin to give at first 
one and then two meals daily of equal parts of oat-jelly, with plain cow's, 
milk heated to 68.3° C. (155° F.), and a little salt added according to the 
infant's taste at the time of the feeding. Freshly prepared barley or 
wheat can, if preferred, be given with milk at this age. 

In the twelfth month I usually accustom the infant to taking a little 
bread one day old with its milk, and to be fed from a spoon, so that by 
the time it is a year old it is taking bread and milk for its breakfast and 
supper, and oat-jelly and milk for the three middle meals. 

Influence of Fat on the Color of FiECAL Dejections. — I have con- 
sidered it of some scientific and practical interest to record the color of 






FEEDING. 217 

the faecal discharges which corresponds apparently to the percentage of 
fat in human milk and in the corresponding modified milk. Plate III., 3 
and 4, facing p. 84, show the color of the normal yellow dejections of two 
infants who were being nursed by their healthy mothers and were them- 
selves digesting well and thriving. 

Plate III., 8 and 9, facing p. 84, represent the color of the normal 
yellow dejections of two infants who were fed on a modified milk which 
corresponded to average human milk. The percentages of the fats, sugar, 
and proteids in this modified milk were respectively 4, 7, and 1. The 
infants were digesting well and thriving. 

The resemblance in color and consistency between the faecal dis- 
charges resulting from human milk and from modified milk in which the 
percentage of fat was 4 is very striking. 

Plate III., 7, facing p. 84, shows the faecal discharges of a healthy in- 
fant fed on a modified milk having a percentage of 3 for its fat, 6 for its 
sugar, and 1 for its proteids. The color of the yellow is much lighter. 

This change of color is still more strikingly illustrated in Plate III., 6, 
facing p. 84, in which the infant was taking modified milk composed of 
fat 2 per cent., sugar 5 per cent., and proteids 1 per cent., and in which 
the resulting faecal discharge had a very much lighter color than in the 
other cases. 

HOME MODIFICATION. — In arranging an infant's food it is best to 
adopt the most simple, precise, and scientific means of expressing what we 
wish to prescribe. This is done by thinking, speaking, and writing our pre- 
scriptions in percentages and by having the food put up by trained clerks 
in a milk-laboratory. In this way we are more certain of obtaining what 
we prescribe than by any other method. When, however, a milk-labora- 
tory is not accessible, or if for any other reason it happens that labo- 
ratory feeding is not available, the mother or nurse should be taught 
to modify the milk in the infant's home. This is what is called Home 
Modification, and under these circumstances much must be taken into 
consideration regarding the details of obtaining and using those mate- 
rials for the modification of milk which it is unnecessary to know when 
the same modification is ordered at a milk-laboratory. It is, in fact, these 
very details which the laboratory, as a saver of time and an instrument 
of precision, supplies for us, and thus makes the exact knowledge of them 
unnecessary. 

Difficulties and Dangers of Home Modification. — It must be impressed 
upon the minds of those who are attempting to modify milk that what 
they are using for this purpose may be a source of great danger to the 
infant consumer. Milk is a dangerous food unless it is carefully pro- 
tected, so that it is first necessary to explain wherein the danger lies, 
and then to learn how to avoid it. Thus only can milk and cream be 
safely used for infant feeding in a household. 

One of the chief dangers from milk and cream lies in the fact that 



218 PEDIATRICS. 

they are such good culture-grounds for pathogenic organisms. The germs 
of such diseases as diphtheria, scarlet fever, typhoid fever, and occasionally 
tuberculosis are well known to be transmitted by milk, and, in addition 
to this, with very little exposure, milk becomes filled with various forms 
of bacteria, many of them virulent, such as the toxin of cholera infantum, 
and all of them foreign to the original purity of the milk as it is elaborated 
in the mammary gland. In this way not only may the diseases just re- 
ferred to be produced, but also various forms of fermental diarrhoea and 
of ileo-colitis. 

The most simple way to avoid the dangers arising from pathogenic 
organisms and from using milks and creams of unknown percentages is to 
obtain these milks and creams of known percentages for modification 
from the milk-laboratories in sealed glass jars. When this is not possi- 
ble, certain primal precautions are to be taken. As the milk-ducts of the 
cow contain, especially in their lower parts, numerous bacteria which 
have gained entrance from without, the ducts should be freed from these 
bacteria by milking a few ounces from each teat, so as to get a milk as 
free from bacteria as possible. Other common sources of contamination, 
such as uncleanness of the cow herself and her udders, should also be 
avoided. The cow should be milked in a clean place and by milkmen 
with fresh, clean clothes, and whose hair has been protected by a suitable 
cap, and whose hands have been thoroughly washed and dried with fresh, 
clean towels. Disease of a virulent nature has been proved to have been 
transmitted through the milk with disastrous effect to the consumer by 
the diseased finger of a milker. 

Another and by no means trivial source of danger is the giving of im- 
proper percentages of the different food-stuffs to the infant in improper 
combinations. This may arise not only from the ignorance of the pre- 
scriber as to what combination of percentages ought to be given in the 
especial case, but also because he may be calculating his percentages on 
a basis which does not correspond to the percentages of the especial ma- 
terials which he is using, materials which must necessarily vary from day 
to day. Under these circumstances the infant may not only suffer from 
all grades of indigestion, leading to serious gastro-enteric disturbance, but 
also contract such diseases of nutrition as infantile atrophy, rhachitis, and 
scorbutus. The physician will not know on what food-combinations these 
diseases have been contracted, for the simple reason that, while he has pre- 
scribed on paper what he supposes to be the correct food for the especial 
case, an entirely different food may result from his not taking into account 
in his calculations the great variety of percentages which may arise not 
only from his failure to appreciate that slight changes in the quantities of 
the materials he is using may result in great percentage differences in the 
food, but also from the fact that although he may calculate the quantity 
of each material correctly, his calculations are rendered worthless by the 
numerical variation in his factors from day to day. These differences in 






FEEDING. 219 

percentages have over and over again in delicate infants proved to be of 
such serious consequence that they cannot be ignored, and every known 
means should be employed to avoid them. The physician should know 
definitely what combination of percentages he is giving in the especial 
case, and then if this combination does not suit the case he will at least 
know that it is his own misconception of what was best to give, and not the 
fault of a combination of percentages, which possibly was really the correct 
one, but which through his mistake was never really given to the infant. 

The difficulty of obtaining a mixture of definite percentage in a home 
modification, in which a milk of unknown fat percentage is used may be 
emphasized in the following manner. Let us suppose that a home modi- 
fication calling for a 2 per cent, fat is made. If the milk in this case is 
from a Jersey cow with high percentage of fat, as, for example, five per 
cent., the resulting proteid will be 1.60 per cent. On the other hand, if 
the milk used to obtain this same 2 per cent, of fat in the modification is 
from a Holstein cow yielding a 3 per cent, fat in the milk, the resulting 
proteid would be (the same quantity of materials being used) 2.66 per cent. 
Therefore, unless the physician knows the fat percentage of the milk he 
is using, he may, by means of the same formula for modification, have a 
variation in his proteids of from 1.60 per cent, to 2.66 per cent. 

Another illustration of what different results in the percentage of the 
proteids may arise from using creams of various percentages is shown in 
the following table : 

TABLE 47. 

Cream used in the Pat obtained by calcula- Lowest possible 

modification. tion in the mixture. proteids. 

Per Cent. Per Cent. 

Ten per cent. . 2 0. 67 

Ten per cent 3 1.00 

Ten per cent 4 1.34 

Twenty-four per cent 2 0.25 

Twenty-four per cent 3 0. 37 

Twenty-four per cent 4 0. 50 

Here it is shown that in a given home modification unless the cream 
used is of known definite percentage the resulting mixture may show pro- 
teids varying from 0.25 per cent, to 1.34 per cent., a difference which in 
most cases of difficult digestion is of very serious import. 

There are other difficulties which arise in using creams in which the 
percentage is exactly known. For instance, when creams, of certain per- 
centages are used it is impossible to obtain in the modification certain per- 
centages of the proteids, so that it is necessary in changing from day to 
day the proteid percentage in a modified milk to have at command creams 
of different fat percentages, such 10, 12, 16, or 20 per cent. Thus, if a 
cream with a 10 per cent, of fat is used the following are the limitations 
as to the lowest possible percentages of the proteids which can be obtained 
from it when different mixtures of fat are desired. 



220 PEDIATRICS. 

TABLE 48. 

Per Cent. 

In a mixture calling for 2 per cent, fat the lowest possible proteid is 0.67 

In a mixture calling for 3 per cent, fat the lowest possible proteid is 1.00 . 

In a mixture calling for 4 per cent, fat the lowest possible proteid is 1.34 

In a mixture calling for 4.50 per cent, fat the lowest possible proteid is 1.67 

Therefore, as is often the case when we wish to use a 3 per cent, or 
4 per cent, fat combined with a fractional percentage of the proteids, or at 
least as low as 1 percent., it will not be possible to make this modification 
with a 10 per cent, cream. In like manner, with a 12 per cent, cream, 
it is impossible to obtain as low a proteid percentage as 1 with as high a 
fat percentage as 2, or even 3, as is shown in the following table : 

TABLE 49. 

Per Cent. 

In a mixture calling for 2 per cent, fat the lowest possible proteid is 0.54 

In a mixture calling for 3 per cent, fat the lowest possible proteid is 0.82 

In a mixture calling for 4 per cent, fat the lowest possible proteid is 1.08 

In a mixture calling for 4.50 per cent, fat the lowest possible proteid is 1.34 

However difficult it may be to obtain a variety of percentage combi- 
nations when we know definitely the percentage of the creams which we 
have at our command, still greater difficulties arise when we have to use 
a gravity cream in a home modification, for gravity cream depends for its- 
percentage of fat on the quality of the milk from which it is obtained, on 
the number of the hours of the setting, and on other conditions such as; 
temperature and handling. A table showing the variations in the per- 
centages of fat in the different layers of milk which has been allowed to. 
set 4, 6, 8, and 10 hours will be found on page 226. 

A gravity cream varies very readily from 8 to 12 per cent., so that 
inaccuracies cannot fail to occur and must be allowed for when a home 
modification of milk is made with a gravity cream. For instance, we may 
suppose that we wish to prescribe a milk modification demanding 3 per 
cent, fat, 6 per cent, sugar, and 1 per cent, proteids, and we make use of 
a cream with a supposed fat percentage of 10. If this cream should vary 
so that its fat was 8 instead of 10 per cent, we should have a mixture 
containing only 2.4 per cent, fat instead of 3. On the other hand, if the 
percentage of fat in the cream was 12, on using the same formula we 
should obtain a mixture containing 3.6 per cent, fat in place of 3 per cent. 
Again, if the cream had been tested and found to contain 8 per cent. fat. 
instead of 10 per cent., and a sufficient quantity of this cream was used 
to produce 3 per cent, fat in the mixture, the proteids would be 1.28 per- 
cent, instead of the 1 per cent, prescribed. On the other hand, if the 
cream was known to be 12 per cent, fat, and a less quantity was added, 
so that the fat in the mixture should be 3 per cent., the proteids would, 
necessarily be reduced to 0.82 per cent. 

Not only do decided variations in the fat percentage of a gravity cream 
arise from the milk of one cow or herd, but there may also be a decided. 



FEEDING. 221 

variation in the creams obtained under the same conditions but from dif- 
ferent herds, and these variations occur whether the cream is siphoned, 
poured off, or skimmed. 

In order to obtain a definite idea of the variation in the fat percentage 
of milk such as one would be likely to purchase for the purpose of 
home modification, I had a series of observations made upon the milk 
obtained from five different dairies in Boston, and hence, presumably, 
from as many different herds. The milk was purchased for three suc- 
cessive days and subjected to the same conditions, and on each day each 
sample of milk yielded practically the same results. In each instance the 
milk was allowed to set for eight hours at a temperature of about 3.3° C. 
(38° F.), and the top quarter carefully poured off and the strength of the 
resulting cream tested with the following results : 

TABLE 50. 

Per Cent. 

Herd A gave a cream with a fat percentage of 6.2 

Herd B gave a cream with a fat percentage of 7 

Herd C gave a cream with a fat percentage of 10 

Herd D gave a cream with a fat percentage of 11 

Herd E gave a cream with a fat percentage of „ . 12 

These experiments seem to show conclusively that given a milk of 
unknown strength, purchased from different sources, the top quarter may 
vary in its fat percentage from 6 per cent, to 12 per cent., and one might 
obtain very wide differences in the percentages of a home modification, in 
which the fat percentage of the milk used is not estimated. 

Variations are especially liable to occur when the milk of one or two 
cows or of a small herd is used, for it is not unusual to find that certain 
cows give widely different cream percentages in the upper eight ounces 
after standing eight hours, such as from 8 per cent, to 1-1 per cent., thus 
making a possible variation of 6 per cent., and it has also been shown by 
the records of the experiment station at Durham, New Hampshire, that 
out of one hundred herds the percentage of fat in the mixed milk of each 
herd varied from 3 per cent, to 6 per cent. 

It is therefore important for the correct home modification of milk that 
the physician should know the analysis of the milk of the special herd of 
cows which he is using, to see whether all his patients are being fed from 
that herd or from a number of herds, and to determine the percentage of 
fat in the milk from the same herd on different days. 

The variation in the fat percentage in different herds is apt to be con- 
siderable, as the owner often has a preference for one or another kind of 
stock, and frequently has a larger portion of that particular kind in his 
herd. It is also well known that the milk of the whole herd, for reasons 
of convenience, is not mixed together each day, and that, therefore, the 
testing of such milk on certain days is misleading, as it may contain little 
or much fat, according as it may have been produced by the poorer or 
richer milk producers of the herd. 



222 PEDIATRICS. 

Owing to the different conditions of the cows and of the feeding 
during the year, and to the fact that the fresh cows which are giving the 
larger quantities of milk will at times happen to be cows giving a low per 
cent, of fat, while at other times the large milkers will be cows which 
yield a high per cent., the variation in the percentage of fat from the 
same herd may in the course of the year often vary as much as 2 per 
cent. It should, therefore, be appreciated that unless the cows are 
especially cared for, as are the herds connected with the milk-laboratories, 
the percentage of fat is constantly varying. If, therefore, it is necessary 
for the physician to use different herds in prescribing, or even if he should 
use the same herd, it will be of great advantage, for accurate modification, 
for him to know the percentage of fat in the milk from time to time and 
change his calculations accordingly. 

These statements hold true when the milk -can be obtained at once 
after milking and under the most favorable circumstances. If, on the 
contrary, an ordinary milk is set after it has passed through the hands of 
a city milkman, the same rules will not apply for obtaining, for instance, a 
10 per cent, cream, as the cream will be likely to have partly risen when 
the milk is delivered, and if it is then set for eight hours, a twenty- or 
twenty-four-hour cream may be the result, which is not only objectionable 
because the cream is old, but because it varies greatly in its fat percentage. 

In making a home modification it must also be noted how appreciably 
the total amounts of milk and cream used for a mixture in which speci- 
fied percentages of fat and proteids are desired must differ according to 
the cream used. For instance, in a 40-ounce mixture, in which 3 per 
cent, fat and 1.50 per cent, proteids are prescribed, 7 ounces of fat-free 
milk and 10 ounces of cream will be required if the cream used is 12 per 
cent. ; while if the cream is 16 per cent, the milk required would be 9.5 
ounces and the cream 7J ounces, and yet the actual percentages of the 
fat and proteids in the two mixtures would be the same. 

The member of the household to whom the modification of the milk 
is intrusted, and to whom the technique of the modification is explained, 
should first be warned that she should always endeavor to prevent im- 
purities from getting into the milk, in preference to trying to eradicate 
them after they have begun to alter the normal composition of the milk. 
She should conscientiously carry out to the minutest detail the directions 
which are given to her. The milk of a herd of cows is preferable to that 
of one cow, for many of the reasons already spoken of, but especially 
because the elemental percentages are less likely to vary in the mixed 
milk of a herd than in that of the individual cow, and because the mixing ■ 
lessens the deleterious effects on the milk arising from occasional disturb- 
ances of health in an individual member of the herd. The cows, if pos- 
sible, should be of a common breed and such as give a moderately rich 
milk. 

The milk should be received into absolutely clean receptacles, thor- 



FEEDING. 223 

oughly strained, and rapidly transferred to a clean and cold place free 
from dust. 

It has been shown by Freeman that when milk is set the great mass 
of the bacteria rise with the cream, so that the separated milk is compara- 
tively free from bacteria, and thus becomes bacteriologically the best 
material for obtaining the required percentage of proteids in a prescribed 
mixture ; the necessity for pasteurization is thus also greatly diminished, 
so far as the milk is concerned. 

Materials for Home Modification. — Certain materials and apparatus 
are required to modify a milk in the home. To obtain the required per- 
centages of the fat resource is chiefly had to creams of various strengths ; 
the sugar is supplied by commercial milk-sugar ; the proteids are derived 
either from whole milk or separated milk, the caseinogen percentage being 
obtained from milk and the lactalbumin mostly from whey. The alka- 
linity can best be regulated by freshly prepared lime-water. The water 
should be freshly distilled or clear water filtered and boiled. 

Definition of Terms. — For the purpose of uniformity it is well that the 
meanings of the terms used in speaking of the materials required for a 
modification of milk should be clearly defined. 

Separated milk means a milk from which the fat has been partially 
or wholly removed, either by the centrifuge or by gravity. 

Pat-free milk means a separated milk which contains no fat, or at 
least only a fractional percentage, such as may be obtained in the lowest 
quarter of a quart of milk which has been setting six or more hours. 

Cream means that which remains after separated milk has been re- 
moved from whole milk. It contains most of the fat of the whole milk and 
certain percentages of all the other elements of whole milk. Its proteid 
percentage is only slightly lower than that of whole milk, the higher fat 
percentage creams showing the greater variations, and none of the creams 
in ordinary use showing a proteid percentage as great as 1 per cent, below 
that of the whole milk from which they are derived. The sugar percent- 
age is slightly lower than in milk, and the salts are slightly diminished. 
When calculations for modifications of milk are being made from formulae, 
it is necessary to take into consideration these variations in the composi- 
tion of cream. A table showing the average analyses of whole milk, 
creams of different strength, fat-free milk, and whey will be found on 
page 227. 

Whole milk, therefore, can be considered a 4 per cent, cream. 

Whey means a milk which contains all its sugar and water while 
most of the fat and all the caseinogen have been removed. The fat per- 
centage is therefore very low, and the proteid percentage as a whole is 
low, the remaining proteids consisting almost entirely of lactalbumin. 

Caseinogen is the mother substance from which the casein is obtained 
by precipitation or coagulation. 

Lactalbumin is the proteid not coagulable by acids and rennet. 



224 PEDIATRICS. 

Apparatus. — The apparatus used in the home modification of milk is 
as follows : 

Home-Sterilizer. — If great precautions are taken to guard the ,milk 
and cream, the mixture made from them need not be pasteurized or 
sterilized. In many cases, however, the physician may deem it safer to 
heat the milk, especially when he is treating a case of gastro-enteric dis- 
turbance, or when in hot weather it is necessary to transport the * food a 
long distance. If heating is ordered, a special apparatus will be required. 
This apparatus, which is called a home-sterilizer, can be obtained at the 
laboratories, or it can be readily devised in the home from a tin pail. Fig. 
55 represents the home-sterilizer. It is simply a tin can supported on its 

Fig. 55. 




Sterilizer and thermometer. Stand for tubes. Sterilizer covered with cozy after removal from heat. 

legs so that it can be heated by a lamp, or, if preferable, the legs can be 
removed and the can placed on a stove. 

Thermometer. — The sterilizer has a lid, to which is fitted a long ther- 
mometer, the lower end of which rests within one of the tubes containing 
the milk, by which the degree of heat within is indicated. 

Tubes. — The tubes, varying in number according to the number of 
feedings which are required in twenty-four hours, are placed in this stand, 
which can be lowered into the sterilizer until the water therein is made 
to rise as high as the level of the milk in the tubes. 

Stoppers. — The tubes are stopped with cotton-wool. 

Cozy. — The sterilizer is covered with a thick cozy, through which the 
thermometer from the lid passes and indicates the degree of heat retained 
within the sterilizer after the flame has been removed. 

Graduate. — A 250 c.c. (81 ounces) glass graduate, divided into half- 
drachms, will be needed. 



FEEDING. 225 

Cotton-Wool. — A roll of aseptic non-absorbent cotton- wool should be 
provided. 

Milk-Sugar. — Milk-sugar must be used. 

Sugar-Measure. — A sugar-measure, which holds 13.5 grammes (3f 
drachms), can be obtained at the laboratories. It holds approximately 
one level tablespoonful. 

Fig. 56. 




Sugar-measure. 

This measure obviates the expense of having the milk-sugar put up in 
packages by the apothecary, and is sufficiently exact to regulate the sugar 
percentage in the mixtures which will presently be referred to. It is well 
to remember, however, that a pound of milk-sugar contains 464 grammes 
(7000 grains), and that if it is preferred to order the sugar in packages of 
13.5 grammes (3f drachms) directly from the apothecary, in place of 
using the measure, one can simply tell him to make thirty-five packages 
from the pound, and the mother can then be directed to use a package of 
milk-sugar instead of a measureful. 

Siphon. — Finally, a glass siphon, 0.6 cm. (J inch) caliber, is needed. 
It may be made by bending a piece of glass tubing to the required length 
and angle by means of a gas-flame. The end out of which the milk is to 
flow should be at least six inches longer than that which is to be inserted 
in the jar, and to it should be attached a piece of rubber tubing one inch 
long with an ordinary clamp. The siphon may easily be filled by placing 
it under a hot- water faucet and then clamping the rubber end. By means 
of the clamp the action of the siphon may easily be controlled. Under 
no circumstances should the mouth be used to start the siphon, for by 
such means pathogenic germs are introduced into the milk. The rubber 
tubing and siphon should be washed first in cold and then in hot water 
immediately after using. 

Method of Obtaining Cream and Fat-free Milk. — In order to obtain 
the fat-free milk and the creams of different percentages the jars of 
milk are to be set in a vessel containing ice and water with some salt in 
the proportion of 5 grammes (1 teaspoonful) to 960 c.c. (1 quart) of water. 
Clean, freshly-boiled cotton cloths are then thrown over the uncovered 
jars. The mouths of the jars are kept open for about fifteen minutes to 
dispose of the animal heat. The jars are then to be sealed tightly, as is 
done in preserving, and are left in the ice-water for a variable number of 
hours according to the fat percentage of cream desired. Care must be 
taken that the temperature of the water does not fall below 1.66° C. 
(35° F.). 

Fig. 57 represents a jar of milk with the siphon (without the rubber 

15 



226 



PEDIATRICS. 



Fig. 57. 



end and clamp) in place. The first 8 ounces removed — that is, the 
lowest 8 ounces — represent what is practically a fat-free milk. The per- 
centages of fat in the upper layers will depend upon the original fat per- 
centage of the milk and upon the number of hours the milk has been 
setting. If the percentage of fat in the milk is unknown, any rules for 
the estimation of the percentage of fat in the upper layers under varying 
conditions can only be approximate. If, however, it is known that the 
milk contains close to 4 per cent, of fat, we may reasonably assume that 
a quart of milk will yield on an average approximately — 

Cream, 10 per cent, in the upper 8 ounces after 6 hours. 
Cream, 10 per cent, in the upper 11 ounces after 8-12 hours. 
Cream, 12 per cent, in the upper 8 ounces after 8 hours. 
Cream, 16 per cent, in the upper 6 ounces after 8 hours. 
Cream, 20 per cent, in the upper 4 ounces after 4-6 hours. 

If the milk is known to be exceptionally poor in fat, containing, for 
instance, only 3 per cent, of fat, it will be safer to take about 2 ounces 

less in each case mentioned above. If the 
milk is unusually rich in fat, containing 5 per 
cent, of fat, it is safer to take 2 ounces more 
in each case mentioned above. If the siphon 
is used to separate the cream layer, the fat- 
free milk is first drawn off, — that is, the 
lowest 8 ounces. By continuing the action 
of the siphon the middle portion of the milk 
is then withdrawn, leaving in the jar 4, 6, 8, 
or 11 ounces of the upper portion, according 
to the percentage of cream desired. Satis- 
factory substitutes for the siphon are Chapin's 
flat-bottomed dipper, or, still better, a dipper 
with a conical bottom. When none of these 
mechanical devices is to be obtained, the 
upper layers may be carefully poured off. 
One of the chief difficulties in making accu- 
rate home modifications lies in the uncer- 
tainty as to what percentage of fat is actually 
present in the cream. If cream of a definite 
strength and fat-free milk are obtained from 
the milk laboratories, the percentage modification of milk can be made 
within very small limits of error. 

The Calculation of Percentage Combinations. — Having obtained the 
materials for the modification, — that is, cream of 10, 12, 16, or 20 per 
cent, strength, fat-free milk to raise the proteid percentage if desired, 
lime-water, boiled or distilled water, and dry milk-sugar, — it now becomes 
necessary to make the calculations for the relative amount of each ingre- 
dient. This may be done in several ways, — either by the means of 




Jar containing milk, cream, and 
siphon. C, cream ; M, milk ; S, si- 
phon. 



FEEDING. 227 

formulae or by the use of a feeding card, both of which methods will be 
described below. 

The only objection to the use of formulae is the time required to cal- 
culate the combinations and the difficulty which some minds experience 
in dealing with anything involving even moderately complicated mathe- 
matics. It will also often be found when the computation is completed 
that the desired combination is impossible with the strength of cream used. 
We may, for instance, calculate for a prescription calling for 4 per cent. fat y 
6 per cent, sugar, and 0.60 per cent, proteids. If we figure on the basis 
of using a 10 per cent, cream, we find the combination impossible, for 
the lowest proteid that can be obtained from a 10 per cent, cream with 
4 per cent, fat in the mixture is 1.34 per cent. We next try a 12 per 
cent, cream, and find the lowest proteid possible is 1.08 per cent. Again 
we calculate with a 16 per cent, cream, and find the lowest proteid is 
0.80 per cent. Finally we try a 20 per cent, cream, and find at last that 
it will yield both the fat and proteid percentages desired. All this obvi- 
ously involves a great waste of time. It is therefore desirable to have a 
system by which it will be evident at a glance what are the combinations 
possible with a cream of given strength. 

As any system relating to the modification of milk must take into 
consideration the composition of the ingredients used, some standard 
analysis must be adopted. Any formulae or table such as given below 
presupposes the acceptance of such a standard. Owing, however, to the 
great variation in the quality of milk, exception may be taken to any 
standard suggested. The analyses which are given below are on the basis 
that the milk used contains 4 per cent, of fat, 4.50 per cent, of sugar, and 
3.50 per cent, of proteids. 

The composition of the different materials used in the modification 
of milk is therefore assumed to be approximately as follows : 

Fat. Sugar. Proteids. 

Per Cent. Per Cent. Per Cent. 

Fat-free milk Trace 4. 60 3. 60 

Whey Trace 4.80 1.00 

Whole milk 4.00 4.50 3.50 

8 per cent, cream 8.00 4.40 3.40 

10 per cent, cream 10.00 4.30 3.35 

12 per cent, cream 12. 00 4. 20 3. 30 

16 per cent, cream 16.00 4.05 3.20 

20 per cent, cream 20.00 3.90 3.10 

The traces of fat in the fat-free milk obtained either by using the 
lowest 8 ounces of a quart of milk after it has been setting eight or more 
hours, or by means of a centrifugal separator, rarely exceeds 0.05-0.1 
per cent., and can therefore be excluded in making the calculations. 

The estimation of a percentage combination may simply and quickly 
be made by means of the following table, which has been arranged 
and calculated by Dr. Maynard Ladd. The data given may be printed 



228 



PEDIATRICS. 



upon a card, which can easily be carried in a pocket-book, and can there- 
fore always be at hand when needed. It is so arranged that the physician 
may exercise a choice in the percentage of cream used, and can see at a 
glance whether a desired combination is possible with a cream of specified 
strength. 

TABLE 51. 





Twentv-ounce Mixtures. 










Ounces of Fat-free Milk 








, 






percentage of 




Ounces of Cream. 


used with Creams of 


Ounces 01 


*T ,£ 


g ° £ 


d 


03 


3 


O 




a 
o 

as 

<o ft 


a> a) 
> o 

is a 


«1 

© o 

-2 u 
.3 p. 


II 


a 

<s 
u 

3 p, 




3 s. 


p £ 

Is. 




mis 
1* 


CO Jo 




^ 


S 


m 


£ 


<~ 


H 


H 


OQ 


H 


H 


H 


02 


H 


3 


PQ 


cc 


1 


1.50 


4.50 


0.25 


5 


* 


* 


* 


1% 
1% 


* 


* 


* 





1 


173^ 


2 


0.33 


2 


1.50 


4.50 


0.50 


5 


3 


2% 


2 





% 


1 


1% 


1 


16 


2 


0.61 


3 


2.00 


5.00 


0.25 


5 


* 


* 


* 


2 


* 


* 


* 





1 


17 


2% 


0.75 


4 


2.00 


5.00 


0.50 


5 


* 


3M 

3*1 

3*| 


2% 


2 


* 





3*1 


1 


1 


15% 
15% 


2% 


0.73 


5 


2.00 


5.00 


0.75 


5 


4 


2 


V\ 


l% 

2% 


1 


1 


2 


1.01 


6 


2.00 


5.50 


1.00 


5 


4 


2 


m 


1 


2% 
2*1 
2*1 
2% 
2% 
2% 


1.30 


7 


2.50 


5.00 


0.50 


5 


* 


* 


33| 


1 


* 


* 





% 


1 


0.73 


8 


2.50 


5.50 


0.75 


5 


* 


4% 
4% 


3*1 


* 


& 


1M 

2% 


2 


1 


14% 


1.01 


9 


2.50 


6.00 


1.00 


5 


5 


3g 

3% 
33| 


2% 


1 


3 M 


1 


13% 


1.23 


10 


3.00 


6.00 


0.50 


5 


* 


* 


3 


* 


* 





1 


15% 


0.84 


11 


3.00 


6.00 


0.75 


5 


* 


5 


3 


* 





1*4 


2 


1 


14 


1.12 


12 


3.00 


6.00 


1.00 


5 


6 


5 


3% 
3% 
33| 

3% 


3 





1 


3)1 

4M 


3 


1 


13 


2*1 

2*1 
2*1 


1.35 


13 


3.00 


6.00 


1.25 


5 


6 


5 


3 


1% 

2% 
5% 


2M 
3% 


4% 
5% 
8% 


1 


11% 


1.35 


14 


3.00 


6.50 


1.50 


5 


6 


5 


3 


1 


10% 


1.91 


15 


3.00 


6.50 


2.00 


5 


6 


5 


3 


6% 


7% 


1 


7*1 


2 


2.68 


16 


3.50 


6.00 


0.50 


5 


* 


* 


* 


3% 
3% 
3*1 


* 


* 


* 





1 


15% 


1 


0.78 


17 


3.50 


6.00 


0.75 


5 


* 


* 


t& 


* 


* 





1 


1 


14% 


1.01 


18 


3.50 


6.50 


1.00 


5 


* 


5% 


* 





1% 


2M 


1 


13% 


1 


1.26 


19 


3.50 


6.50 


1.25 


5 


7 


5% 


ti 


3% 
3% 


% 


3*1 


3 


4 


1 


H% 


1.68 


20 


3.50 


6.50 


1.50 


5 


7 


5% 


2 


4% 


5% 


1 


10 


2*4 


2.02 


21 


4.00 


6.00 


0.60 


5 


* 


* 


* 


4 


* 


* 


* 





1 


15 


2% 


0.78 


22 


4.00 


6.00 


0.75 


5 


* 


* 


5 


4 


* 


* 





1 


1 


14 


2% 
2% 
2*1 


1.12 


23 


4.00 


7.00 


1.00 


5 


* 


* 


5 


4 


* 


* 


1 


2 


1 


13 


1.35 


24 


4.00 


7.00 


1.25 


5 


* 


6% 

m 

m 

6% 


5 


4 


* 


1 
i 

10% 
10% 


2% 


3% 


1 


11% 


1.68 


25 


4.00 


7.00 


1.50 


5 


8 


5 


4 


1 


4 


5 


1 


10 


2% 


2.02 


26 


4.00 


7.00 


2.00 


5 


8 


5 


4 


3% 


6% 

12*f 


7% 


1 


7% 


2% 


2.56 


27 


4.00 


7.00 


2.50 


5 


8 


5 


4 


eg 

9*1 
9*| 
9g 


10*1 


1 


4% 
1% 
1% 


2 


3.20 


28 


4.00 


7.00 


3.00 


5 


8 


5 


4 


13K 
13*| 


1 


1% 


3.88 


29 


4.00 


6.00 


3.00 


5 


8 


5 


4 


12*| 


1 


1 


3.88 


30 


4.00 


5.50 


3.00 


5 


8 


5 


4 


10% 


12*f 


13% 


1 


IjJ 


% 


3.88 



* Combination impossible with percentage of cream indicated. 

The amounts given above are for twenty-ounce mixtures. 

For 25-ounce mixtures multiply the amount of each ingredient by 1\. 
For 30-ounce mixtures multiply the amount of each ingredient by 1J. 
For 35-ounce mixtures multiply the amount of each ingredient by If. 
For 40-ounce mixtures multiply the amount of each ingredient by 2. 
For 45-ounce mixtures multiply the amount of each ingredient by 2^. 

On page 188 will be found a table to be used in connection with the 
card, giving the general rules for feeding in reference to the intervals, 
number of feedings, and amounts at each feeding, according to the age 
of the child. 

A few examples may illustrate the facility with which a milk modifi- 
cation may be calculated by means of the above card. 

It is desired to give a baby of seven months six feedings of 6 J ounces 
in the course of twenty-four hours, the prescription calling for — 

Fat 4.00 per cent, (to be obtained with 10 per cent, cream). 

Sugar 7.00 per cent. 

Proteids 2.00 per cent. 

Alkalinity 5.00 per cent. 



FEEDING. 229 

that is, 39 ounces of formula 26 are required ; the calculation is made 
as a matter of convenience for 40 ounces. The process is as follows : 

Of 10 per cent, cream use ( 8 X 2) 16 ounces. 

Of fat-free milk use (3J X 2) 7 ounces. 

Of lime-water use ( 1 X 2 ) 2 ounces. 

Of boiled water use (7J X 2) 15 ounces. 

Of dry lactose use (2^ X 2) 4J measures. 

The mother is instructed where to buy the 10 per cent, cream and 
fat-free milk, or how to get both by setting the milk as described 
above. She is then told to dissolve the dry sugar in a portion of the 
water and to add sufficient water to make 15 ounces. The 7 ounces 
of fat-free milk, the 2 ounces of lime-water, and the 16 ounces of cream 
are then added. The resulting mixture is divided into six tubes, each 
containing 6 J ounces, and these are heated or not as the physician 
requires. 

It may be desirable to prescribe a different percentage of sugar in the 
above mixtures than given in the table ; for instance, in the above ex- 
ample, 6 per cent, instead of 7 per cent. This is easily calculated by 
referring to the last column of the table, which gives the percentage of 
sugar contributed by the cream and fat-free milk, which is seen to be 
about 2.50 per cent. ; the desired amount is 6 per cent. ; therefore dry 
sugar must be added to the extent of 3.50 per cent., which may easily be 
estimated by remembering that 

One measure of dry lactose in a 20-ounce mixture gives 2.00 per cent, of sugar. 
One-half measure of dry lactose in a 20-ounce mixture gives 1.00 percent, of sugar. 
One-quarter measure of dry lactose in a 20-ounce mixture gives 0. 50 per cent, of sugar. 
(One measure holds 3f drachms of lactose. ) 

If in the above prescription 10 per cent, of alkalinity had been de- 
sired instead of 5 per cent., one more ounce of lime-water and one less 
ounce of boiled water should be taken for each 20 ounces. 

Cereal solutions can be added in place of the boiled water, and the 
percentage of starch in the mixture can then be accurately determined, 
if the strength of the cereal solution is known, by multiplying the number 
of ounces of cereal solution used by its percentage of starch and dividing 
the result by the total number of ounces in the mixture. If, for instance, 
in the above example, 15 ounces of a 1 per cent, solution of barley- 
water be added in place of the boiled water the percentage of starch in 
the mixture is 

15X1 



40 



0.375 per cent. 



Whey-Cream Mixtures in Home Modification. — Dr. Ladd has also 
devised a simple way of estimating whey-cream mixtures in connection 
with the above card. Whey contains about 1 per cent, of proteids and 



230 PEDIATRICS. 

about 4.8 per cent, of lactose ; therefore each 2 ounces of whey replacing 
an equal quantity of water in a twenty-ounce mixture will raise the whey 
proteid percentage 0.10 and will increase the lactose percentage 0,50. 
If, then, whey is added to a mixture in place of an equal quantity of 
water, the total whey proteid percentage in the mixture is that obtained 
from the whey plus that which is contributed by the cream and fat-free 
milk. (One-fifth (|) of the total proteid is whey proteids, while the 
remaining four-fifths (-f) is caseinogen.) In a similar way the total sugar 
percentage in a whey-cream mixture is the sum of the amounts con- 
tributed by the whey, the cream, and the fat-free milk. 

Example. — If in formula 21, 14 ounces of whey are added in place 
of 14 ounces of water, the whey proteids are increased 0.70 per cent. 
The total proteid obtained from the cream is 0.60, one-fifth of which 
(0.12 per cent.) is whey proteids and four- fifths of which (0.48 per cent.) 
is caseinogen, so that the final composition of the mixture in reference 
to the proteids is as follows : 

Whey proteids (0.12 -f 0.70) = 0.82 

Caseinogen = 0. 48 

Total proteids = 1.30 

It is thus seen that the total proteids in formula 21 have been raised 
from 0.60 per cent, to 1.30 per cent, without increasing the percentage 
of caseinogen, which makes cow's milk so difficult to digest in cases of 
weak proteid digestion. In cases of difficult proteid digestion, the whey 
should be used in those formulae calling for proteid percentages of 0.25, 
0.50, 0.60, or 0.75, in order to keep the percentage of caseinogen low, — 
that is, down to 0.20, 0.40, 0.48, or 0.60, — while the whey proteids may 
be increased to whatever percentage desired up to the limit determined 
by the number of ounces of diluent used. 

In estimating the sugar percentage in the above example, it is seen 
by referring to the card that the percentage of sugar contributed by the 
cream is 0.78 (see last column of card); the 14 ounces of whey added 
3.50 per cent, of sugar, making a total sugar (or lactose) percentage of 
4.28. In formula 26 the desired percentage of sugar is 6 ; therefore the 
balance of 1.72 may be obtained, as seen by referring to the table on 
page 229, by adding a little less than one measure of sugar. 

Westcott's Mechanical Calculator. — Dr. Westcott, of Philadelphia, 
has constructed an ingenious device for rapid calculation of modifications. 
It is based on the use of 16 per cent, cream, whole milk, and dry sugar. 
It consists of three disks arranged over one another and so marked that 
by a simple method of adjustment one may tell at a glance what propor- 
tions of cream, whole milk, and dry sugar are required for the desired 
percentage combination. With the data thus obtained, the calculation of 
the amounts of the materials used may quickly and simply be made. 



FEEDING. 231 

THE THEORY OP PERCENTAGE MODIFICATION. — Dilution 
of Creams with Whole Milk. — Although a number of combinations of 
various percentages of fat and sugar can be obtained by diluting creams 
with whole milk, yet, the proteid percentage in any instance does not bear 
the same ratio to the fat percentage as holds in the cream from which the 
dilution is made. The finer variations in the relative proportions of fat 
and proteids which are easily obtained by systematized modification in the 
laboratories are impossible by the simple dilution of cream. 

The following table shows the fat percentages of cream which can be 
obtained by diluting a 20 per cent, cream with whole milk. 

TABLE 52. 

1 part 20 per cent, cream -f- 3 parts whole milk = 8 per cent, cream. 
1 part 20 per cent, cream -f- 1 part whole milk = 12 per cent, cream. 
3 parts 20 per cent, cream -f- 1 part whole milk = 16 per cent, cream. 

Dilutions of Cream with Water. — If cream of definite percentages of 
fat, sugar, and proteids are diluted with equal or multiple quantities of 
water, various mixtures are obtained in which the percentages of these 
three elements bear a fixed ratio to those of the cream used. (Westcott.) 
The percentages of the dilution can easily be calculated by multiplying 
the percentages of the cream by a fraction of which the numerator is the 
integer representing the quantity of cream, and the denominator the in- 
teger representing the sum of the quantity of the cream and of the diluent. 
Thus, for an 8 per cent, cream with percentages of 8 per cent, fat, 4.40 
per cent, sugar, and 3.90 per cent, proteids, a mixture of equal parts 
cream and water would give 4 per cent, fat and 1.95 per cent, proteids. 
The resulting sugar percentage avouIcI also bear the same fixed ratio to 
that of the sugar percentage in the cream. 

Dilutions of Cream with Solutions of Sugar. — If it is desired to 
obtain various combinations of fat, sugar, and proteids by diluting creams 
with solutions of sugar, the various percentages of sugar solution can be 
obtained by dissolving one ounce of milk-sugar in twenty ounces, sixteen 
and one-half ounces, fourteen and one-quarter ounces, twelve and one- 
half ounces, or ten ounces of boiled or distilled water, which results re- 
spectively in sugar solutions of 5, 6, 7, 8, or 10 per cent. (Westcott.) 
When these sugar solutions are used as the diluent the calculation of the 
resulting sugar percentage can be made by the following formula, which 
expresses the fact that the sugar percentage of the dilution is the sum of 
the percentages contributed by the sugar solution and the cream. 

s_ WXs'+(CXc) 

w + c 

In this equation S represents the resultant sugar percentage ; W represents 
the quantity of water ; s' represents the percentage of the sugar solution ; 
c represents the percentage of sugar in the cream ; and C represents the 
quantity of cream. 



232 



PEDIATRICS. 



For example, for a dilution of 1 part of 12 per cent, cream to 3 parts 
of an 8 per cent, sugar solution the resulting percentages would be 3 per 
cent, fat and 0.95 per cent, proteids, while the sugar percentage would be 



S== 3X8+ (1X4.20) 
3 4- 1 



28.20 
4 



7.05. 



The following tables have been prepared by Dr. T. S. Westcott to show 
the different resulting fat, sugar, and proteid percentages obtained by mix- 
ing in various proportions different sugar percentage solutions with 4 per 
cent, fat cream (i.e., whole milk), 8 per cent, fat cream, 12 per cent, fat 
cream, and 16 per cent, fat cream. A slightly different standard of analy- 
ses of milk and creams from that given on page 227 is adopted by West- 
cott in the following tables and formulae in order to simplify them. 

TABLE 53. 

3 parts of milk to 

1 part 5 to 10 per cent, sugar solution = fat, 3.00 ; sugar, 4.60 to 5.85 ; proteids, 3.00 



1 part of milk to 

11 parts 5 to 7 per cent, sugar solution 
7 parts 5 to 7 per cent, sugar solution 
3 parts 5 to 8 per cent, sugar solution 
1 part 5 to 10 per cent, sugar solution 



TABLE 54. 

Four per cent. Cream {whole milk) . 
Fat, 4.00; Sugar, 4.4O ; Proteids, 4. 00. 



fat, 0.33 ; sugar, 4.95 to 6.78 ; proteids, 0.33 

fat, 0.50; sugar, 4.92 to 6.67; proteids, 0.50 

fat, 1.00; sugar, 4.85 to 7.10; proteids, 1.00 

fat, 2.00; sugar, 4.70 to 7.20; proteids, 2.00 



Fat, 



TABLE 55. 

Eight per cent. Cream. 
8.00; Sugar, 4.30; Proteids, 3.90. 



1 part of cream to 

7 parts 5 to 7 per cent, sugar solution = fat, 1.00 ; sugar, 4.91 to 6.66 ; proteids, 0.49 

3 parts 5 to 8 per cent, sugar solution = fat, 2.00 ; sugar, 4.82 to 7.07 ; proteids, 0.97 

16 parts 5 to 8 per cent, sugar solution = fat, 3.07 ; sugar, 4.73 to 6.58 ; proteids, 1.41 

1 part 5 to 10 per cent, sugar solution = fat, 4.00 ; sugar, 4.65 to 7.15 ; proteids, 1.95 



TABLE 56. 

Twelve per cent. Cream. 
Fat, 12.00; Sugar, 4.20; Proteids, 3.80. 



1 part of cream to 

11 parts 5 per 

11 parts 6 per 

11 parts 7 per 

7 parts 5 to 7 per 

5 parts 5 to 7 per 

3.8 parts 5 to 8 per 

3 parts 5 to 8 per 

2.4 parts 5 to 8 per 

2 parts 5 to 8 per 



cent, 
cent, 
cent, 
cent, 
cent, 
cent, 
cent, 
cent, 
cent. 



sugar 
sugar 
sugar 
sugar 
sugar 
sugar 
sugar 
sugar 
sugar 



solution 
solution 
solution 
solution 
solution 
solution 
solution 
solution 
solution 



fat, 1.00; 
fat, 1.00; 
fat, 1.00; 
fat, 1.50; 
fat, 2.00; 
fat, 2.50; 
fat, 3.00 ; 
fat, 3.53; 
fat, 4.00; 



sugar, 
sugar, 
sugar, 
sugar, 4.90 
sugar, 4.87 
sugar, 4.83 
sugar, 4.80 
sugar, 4.76 
sugar, 4.73 



4.93; 

5.85; 

6.76; 
to 6.65; 
to 6.53; 
to 7.20; 
to 7.05; 
to 6.88; 
to 6.73; 



proteids, 0. 32 
proteids, 0.32 
proteids, 0.32 
proteids, 0.48 
proteids, 0.63 
proteids, 0.79 
proteids, 0.95 
proteids, 1.12 
proteids, 1.27 



FEEDING. 



233 



TABLE 57. 

Sixteen per cent. Cream. 

Fat, 16.00; Sugar, 4.00; Proteids, 3.60. 



1 part of cream to 

15 parts 5 per cent, sugar solution = fat 
15 parts 6 per cent, sugar solution = fat, 
15 parts 7 per cent, sugar solution — fat, 
9 parts 5 per cent, sugar solution = fat 
9 parts 6 per cent, sugar solution = fat 
9 parts 7 per cent, sugar solution = fat, 
7 parts 5 per cent, sugar solution = fat 
7 parts 6 per cent, sugar solution = fat 
7 parts 7 per cent, sugar solution = fat 
5.4 parts 5 per cent, sugar solution = fat, 
5.4 parts 6 per cent, sugar solution = fat 
5.4 parts 7 per cent, sugar solution = fat 
4.3 parts 5 per cent, sugar solution = fat 
4. 3 parts 6 per cent, sugar solution = fat 
4.3 parts 7 per cent, sugar solution = fat 
3.6 parts 5 per cent, sugar solution = fat 
3.6 parts 6 per cent, sugar solution = fat, 
3.6 parts 7 per cent, sugar solution = fat 
3 parts 5 per cent, sugar solution = fat 
3 parts 6 per cent, sugar solution = fat. 
3 parts 7 per cent, sugar solution = fat 
3 parts 8 per cent, sugar solution == fat 

Dilutions of Creams with Whey 



1.00 
1.00 
1.00 
1.60 
1.60 
1.60 
2.00 
2.00 
2.00 
2.50 
2.50 
2.50 
3.02 
3.02 
3.02 
3.48 
3.48 
3.48 
4.00 
4.00 
4.00 
4.00 



sugar, 4.94 
sugar, 5.87 
sugar, 6.81 
sugar, 4.90 
sugar, 5.80 
sugar, 6.70 
sugar, 4.87 
sugar, 5.75 
sugar, 6.62 
sugar, 4.84 
sugar, 5.70 
sugar, 6.53 
sugar, 4.81 
sugar, 5.62 
sugar, 6.43 
sugar, 4.78 
sugar, 5.56 
sugar, 6.35 
sugar, 4.75 
sugar, 5.50 
sugar, 6.25 
sugar, 7.00 



proteids, 0.23 
proteids. 0.23 
proteids, 0.23 
proteids, 0.36 
proteids, 0.36 
proteids, 0.36 
proteids, 0.45 
proteids, 0.45 
proteids, 0.45 
proteids, 0.56 
proteids, 0.56 
proteids, 0.56 
proteids, 0.68 
proteids, 0.68 
proteids, 0.68 
proteids, 0.78 
proteids, 0.78 
proteids, 0.78 
proteids, 0.90 
proteids, 0.90 
proteids, 0.90 
proteids, 0.90 



-When it is desired to increase in a 
mixture the relative proportion of the lactalbumin to the caseinogen, 
whey can be used for this purpose. There are, however, in doing this, 
certain precautions which must be taken, since the excess of pepsin re- 
sulting from the preparation of the whey is apt to precipitate the case- 
inogen of the proteids in the cream, and to leave coagula in the mixture. 
To obviate this the whey should be raised to a temperature of 65.5° C. 
(150° F.) for five minutes in order to destroy the rennin, and then 
allowed to cool before mixing it with the cream, especially when the 
total quantity of food for twenty-four hours is prepared at one time. 
This procedure, however, seems to be unnecessary when the whey is 
added to cream and milk mixtures which have been partially pepto- 
nized. In this case the amount of whey to be added should first be 
decided upon and then this quantity should be deducted from the quan- 
tity of diluent used, so that when the whey is added the total quantity 
shall not be altered. If this be done, the increase in proteids (0.86) 
contributed by the whey can be calculated by multiplying 0.86 by the 
number of ounces of whey and dividing the product by the total num- 
ber of ounces in the prescribed mixture. Since the proteid (lactal- 
bumin) percentage of whey is less than 1 per cent., a very nutritious mix- 
ture may be obtained by using undiluted whey and bringing up the fat 
percentage by the addition of cream. 

In this case, since there is no diluent, the fat percentage cannot be 
varied altogether at will, but must depend upon the desired proteid per- 
centage and vice versa. 



234 



PEDIATRICS. 



The proteid percentage, however, for any definite fat percentage can 
be varied by making use of different grades of cream. Thus, with a 3 
per cent, fat (F), proteids ranging from 1.18 (from a 20 per cent, cream) 
up to 1.92 (from an 8 per cent, cream) can be obtained, and with a 4 per 
cent, fat (F) a variation of proteids between 1.30 per cent, and 2.32 per 
cent, can be similarly obtained. 

The formula by which the amount of cream (C) to be used in a total 
mixture (Q) in which the diluent is whey is as follows : 

^ Q[F(fat p. c. in cream used) — 0.32 (fat p. c. in whey) ] 

7.68 or 11.68 or 15.68 or 19.68 

according as a cream of fat 8 per cent., 12 per cent., 16 per cent., or 20 
per cent, is used. 

The following table gives the varying combinations of fat and proteids 
that can be obtained by mixtures of whey and creams of various fat 
percentages. For the sake of comparison the quantities of cream re- 
quired for a mixture of twenty ounces have been given in the final 
column : 

TABLE 58. 

Combinations of fat and proteid percentages which can be made by creams of 4 per 
cent., 8 per cent., 12 per cent., 16 per cent., and 20 percent, diluted with whey, containing 
a fat percentage of 0.32. 














Cream in Twenty-ounce 










Mixture, the Balance 


With 


20 per cent. Cream. 






Whet. 




For 1.00 F. 


P. 


= 0.94 


0. 70 ounce. 




For 2.00 F. 


P. 


= 1.06 


1.71 ounces. 




For 3. OOF. 


P. 


= 1.18 


2.72 ounces. 




For 4.00 F. 


P. 


== 1.30 


3. 74 ounces. 


"With 


16 per cent. Cream. 










For 1.00 F. 


P. 


= 0.98 


0.87 ounce. 




For 2.00 F. 


P. 


= 1.15 


2.14 ounces. 




For 3. OOF. 


P. 


= 1.32 


3.42 ounces. 




For 4.00 F. 


P. 


= 1.50 


4.69 ounces. 


"With 


12 per cent. Cream. 










For 1.00 F. 


P. 


= 1.03 


1.16 ounces. 




For 2. OOF. 


P. 


= 1.28 


2.88 ounces. 




For 3. OOF. 


P. 


= 1.53 


4.59 ounces. 




For 4.00 F. 


P. 


= 1.79 


6.30 ounces. 


"With 


8 per cent. Cream. 










For 1.00 F. 


P. 


= 1.13 


1.77 ounces. 




For 2.00 F. 


P. 


= 1.53 


4.38 ounces. 




For 3. OOF. 


P. 


= 1.92 


6.98 ounces. 




For 4.00 F. 


P. 


= 2.32 


9.58 ounces. 


With 


4 per cent. Cream ( 


Milk). 








For 1.00 F. 


P. 


= 1.44 


3.69 ounces. 




For 2.00 F. 


P. 


= 2.29 


9.13 ounces. 




For 3.00 F. 


P. 


= 3.15 


14.56 ounces. 




For 4.00 F. 


P. 


= 4.00 


20.00 ounces. 



FEEDING. 235 

Preparation cv Sweet Whey. — Sweet whey is best made by the fol- 
lowing method : For each pint of whey needed, take one quart of whole 
fresh milk or fat-free milk, heated to 37.7° C. (100° F.), and add 8 c.c. 
(2 drachms) of the essence of pepsin or some of the preparations of 
liquid rennet. This will precipitate the casein in the form of a curd, 
which is then broken up with a fork, and the fluid which remains is the 
whey. This is strained through two thicknesses of boiled cheese-cloth 
and one thickness of absorbent cotton and slowly cooled to a tempera- 
ture of 10° C. (50° F.), and kept on ice until needed. If the whey 'is 
to be mixed with cream, it must first be heated to 65.5° C. (150° F.), 
in order to kill the rennet enzyme. Whey mixtures should not be heated 
above 68.3° C. (155° F.) if one wishes to keep safely under the coagula- 
tion point of the lactalbumin. 

General Formulae for Calculation of all Percentage Combinations. — 
The following formulae and equations, calculated by Westcott, can be 
used for obtaining any combinations of the percentages of the fat, sugar, 
and proteids of milk prescribed, provided that creams of varied fat per- 
centages are used, as has been already explained. The mixtures with 
cream may be made with whole milk, with fat-free milk, and with whey. 
The following symbols will be used : 

F = prescribed percentage of fat. 

S = prescribed percentage of sugar. 

P = prescribed percentage of proteids. 

C = total quantity of cream in ounces. 

M = total quantity of milk in ounces. 

W = total quantity of water in ounces. 

L = total quantity of dry milk-sugar in ounces. 

Q = total quantity of mixture. 

a and a' === known percentage of fat in cream and milk respectively. 

b and b' = known percentage of proteids in cream and milk re- 
spectively. 

c and c' == known percentage of sugar in cream and milk respectively. 

Since the actual quantity of proteids in a percentage mixture is the 
sum of the quantities of proteids contributed by the milk and the cream, 
and, again, since the actual quantity of fat is the sum of the quantities of 
fat contributed by the milk and the cream, the following fundamental 
formulae represent these facts. Since P, F, etc., are represented by 
integers instead of hundredths, the following equations (1) and (2) should 
for greater accuracy be expressed as divided by 100, as already expressed 
in the formula for sugar on page 237 ; but since both sides of the equation 
are divided by 100, the equality of the numerators is also true. 

(1) QXP = VM + bC. 

(2) QX^ = a / M-faC. 



236 PEDIATRICS. 

And since the same reasoning applies to the actual quantity of sugar 
in the mixture with the addition of the dry sugar needed to bring the 
percentage up to the percentage of sugar prescribed, we have 

(3) Q S_^M cC _ 

v ' 100 100 100 

Transposing (1), so as to get a value for M, we obtain 

(4.) M _QF-bC 

If this value of M is substituted in equation (2) we have, by transposi- 
tion and collecting 



(5) C 



Q (b'F — a / P; 



aV-a'l) 

By finding a value for M, from (2) instead of (1) we have 

(6) M = Q:F — aC . 

a 7 „ 

From equation (3), by transposition, we obtain 

L== QS-(c/M + cC) 
V ' 100 

These formulae are of universal application for any strengths of the 
cream and milk percentages. It should be noted that Westcott has 
adopted, for ease of computation, a slightly different standard of composi- 
tion of materials used, based on the assumption that whole milk contains 
fat 4.00 per cent., sugar 4.40 per cent., and proteids 4.00 per cent. 

Formulae for Cream and "Whole Milk (4 per cent. Cream). — Thus, 
for a combination of 16 per cent, cream (a = 16, b = 3.6, S = 4), and 4 
per cent, milk (a' = 4, b' = 4, S == 4.40), as a' and b' are equal, this 
value can be taken out of the numerator and the denominator of (5), 
leaving 

( 8) c = Q( F - p ) 



a — b 

Substituting values for a and b, the formula becomes 



(9) C 

v ; 16 — 3.6 12.4 



= Q(F — P) = Q (F — P) 
and formula (6) becomes 



(10) M = QF-16C^QF_ 4C 

v ' 4 4 

In the same way, for a 12 per cent, cream (a = 12, b = 3.8, S = 4.20) 
and a 4 per cent, milk, formula (8) becomes 

(in C = Q(F-P) = Q(F-P) 

v ; 12 — 3.8 8.2 



FEEDING. 287 

and (6) becomes 

(12) m== qe— 12C ^QF_ 3C 

4 4 

Similarly, for 10 per cent, cream (a = 10, b = 3.85, S== 4.25) 
formula (8) becomes 

(13) C== Q(E- F) == Q(F-F) 

v J 10 — 3.85 6.15 ' 

(14) M=4I-I°°. 

V > 4 4 

Formulae for Cream and Fat-free Milk. — When in place of mixing 
the cream with whole milk a fat-free milk is used, we take formula (5) and 
substituting for the fat value (a') of the milk we get 

c= Q(vr-QXP) = QVP = QP 

K ' aV-OXb aV a' 

and from (4) we get 

Thus, for 16 per cent, cream and fat-free milk (15) becomes 
and (16) becomes 

(18) M = QP-3.60C t 



(16) M=Q P - bC 



(17) C =§><*- or I-XQ 

v ; 16 16 



In the same way, with 12 per cent, cream, 

(19) C =^-X Q - 

(20) M = QP-3.80C 

In the same way, with 10 per cent, cream, 

(21) C=lxQ- 

(22) M = QP — 3.85C 

The formula for sugar does not vary much. Formula (7) is of uni- 
versal application, and, assuming the sugar percentage of milk and cream 
to be about 4.40, (7) would become 

(23) Q S -4.40(M + C ) j 
1 ; 100 

It must be remembered when using these general formulae for any 
combination of percentages, as, for instance, in Formula 8, that when 
P = F it is evident that C = ; or, in other words, that the mixture be- 



238 PEDIATRICS. 

comes a simple dilution of milk, which gives equal percentages of proteids 
and fat. When P is greater than F, the value of C becomes a negative 
quantity, which indicates that the milk needs the addition of proteids 
without fat. This calls for fat-free milk. The calculations of the quan- 
tities for such a mixture can be carried out by the formulae given in the 
various formulae derived from (15) and (16). 

Formulae for Cream and Whey. — In order to calculate the amount 
of whey which is needed for various combinations, the general formulae 
(5), (6), and (7) can be applied by considering whey as a milk containing* 
very low proteids (lactalbumin) and fat. Taking Konig's formula for whey 
as a standard, 

Fat 0.32 — a' 

Sugar , . 4. 79 = c / 

Proteids 0.86= d' 

we can then represent a 7 of the general formula by 0.32, b' by 0.86, 
and c' by 4.8, and the special formula will then be 

(24) C = Q(°- 86 XP — 0-32 XP ) 

V ; 9.1 or 12.6 ' 

according as twelve per cent, or sixteen per cent, cream is used. 

(25) Whey = Q F - 12C or <* F " 16 C 
v ' J 0.32 0.32 

and 

(26) L = Q S — (4.8X^ h ey •+ 12 or 16 C) 
1 j 100 

In such a combination sufficient diluent must be added to make up 
the total quantity. 

The following formulae are derivable from equations expressing the 
fact that the proteid or fat percentage of the mixture is equal to the sum 
of the proteid or fat percentages contributed by the cream and the whey.. 

(27) P= .C xb + whp xb/ 

(28) F= C X a + ^Xa' 

whence, by deduction, 

(29) C = ^^). 
K } a — a' 

One or the other of these formulae may be used according as a definite 
fat or proteid percentage is desired. The constants a and a' represent 
the fat percentages of the cream and of the whey respectively, and b and 
b' represent the corresponding proteid percentages. 

Thus, for 20 per cent cream (F = 20, P = 3.20, S = 3.80) and whey 
(F == 0.32, P = 0.86, S = 4.8) the formulae would become 

(30 ) c= Q(P-0.86) = (81) QL_(Pn0^6) 

V ' 3.20 — 0.86 k ] 2.34 ' 



FEEDING. 239 

and 

(32) c== Q(F-0.32) = (33 . Q(F — 0.32) 

20 — 0.32 V ' 19.68 

The formula for L can be derived from the general formula (7) by sub- 
stitution, which gives 

, U) L _ Q S — (4.8 whey -f 3.8 C) 

* J ^^ 100 

In the same way, for 16 per cent, cream the formulae become, after 
substitution, 

(35) c= Q(P-0.86) 

(36) c = Q(F-0.32 }j 
v ; 15.68 

For 12 per cent, cream, 

(37) 



(38) 

For 8 per cent, cream, 

(39) 
(40) 



Q(F — 0.86) 
2.94 

Q (F — 0.32) 
11.68 

Q (F — Q.86) 

3.04 ' 

Q (F — 0.32) 



Final Remarks on Home Modification. — If a careful study be made of 
what has been said under home modification, in comparison with the 
methods and results of preparing a food at the laboratory, it will be seen 
how uncertain must be most of the modifications which are made in the 
homes by mothers and nurses. While, therefore, in many cases the milk 
must be modified at home, it must be recognized that it probably only 
approaches in exactness the modification by the clerks at the laboratory,, 
where it is done well with all the factors of the problem taken into con- 
sideration, and that in most cases in a home modification the infant is not 
securing as a food what the physician has prescribed and takes for granted 
the infant is getting. 

Directions for making- Oatmeal- Water, Oat-Gruel, and Oat-Jelly. 

Oatmeal-Water. — Put two ounces of oat flour into one quart of water, 
boil for twenty minutes, let it stand for twenty minutes, and then pour 
off the water, straining it through a piece of thin white cloth which has 
been boiled. 

Oat-Gruel. — Put four ounces of oat flour into one quart of water, boil 
for twenty minutes, add water enough to replace what has evaporated,, 
and strain, while hot, through a thin white cloth. 

Oat-Jelly. — Put six ounces of oat flour into one quart of water, boil 
for twenty minutes, add water enough to replace what has evaporated, 
and strain, while hot, through a thin white cloth. This makes a very 
thick jelly. 



240 PEDIATRICS. 

To measure the flour use a graduate, and measure as for fluidounces. 

Barley-water, barley-gruel, and barley-jelly may be made in a similar 
way, following the same directions, but using the prepared barley flour. 

Wheat. — Wheat can be prepared by the same method as that de- 
scribed for oats and barley. 

Peptonized Milk. — Milk may be partially or wholly peptonized in 
home modification by the same methods as described under laboratory 
feeding, on page 202. 

ARTIFICIAL FOODS FOR INFANTS.—It would seem hardly 
necessary to suggest that the proper authority for establishing rules for 
substitute feeding should emanate from the medical profession, and not 
from non-medical capitalists. Yet, when we study the history of artificial 
feeding as it is represented all over the world, the position which the 
family physician occupies, in comparison with that of the venders of the 
numberless patent and proprietary artificial foods administered by the 
nurses, is a humiliating one, and should no longer be tolerated. 

If we are abreast of the times, if we but recognize and do justice to 
the work which has lately been done by our own profession, we surely 
will not hesitate to relegate to oblivion the statements of the food proprie- 
tors, which on box and can, on bottle and printed circular, attempt to 
stem the slow but inevitably progressing wave of scientific investigation. 

It may be well to bear in mind that the attempts which in the past have 
been made to manufacture cheap foods have been marked by failures. We 
must first, regardless of expense, learn to produce by modification a per- 
fected substitute food, and not endanger the success of our undertaking by 
allowing the mercantile side of the question to cripple us in the use of costly 
methods, which, however, we know to be the best. We should, in fact, 
remember that the human milk, which we are endeavoring to copy, far 
from being a cheap product, is a very expensive one. 

My own opinion in regard to patent foods, as a whole, is that they must 
necessarily be unreliable. They are thrown on a market where the com- 
petition is extreme, and when once they have been advertised into public 
notice I cannot but feel that irregularities and changes — slight, perhaps, in 
the eyes of the makers — may unintentionally creep in and carry their com- 
position still farther from that of the standard, human milk. 

Analyses show that there is a lack of uniformity in these foods from 
year to year, and that original claims are apparently forgotten or allowed to 
give way to cheaper production. In fact, as my experience in the feeding 
of infants increases, and as I examine year by year the effects of the different 
foods on infants, I am strongly impressed with the belief that with our pres- 
ent physiological, chemical, and clinical knowledge all the patent foods are 
entirely unnecessary. The claims made for them are not supported by in- 
telligent and unprejudiced investigation. Those who manufacture them are 
not in a position to judge correctly concerning them. The merit at times 
of their apparent success does not belong to them, but to accompanying 



FEEDING. 241 

circumstances. They do great harm by impressing upon the public the 
false idea that a cheap, easily prepared food is for the good of the infant and 
is better than anything which can be procured elsewhere. They vary too 
greatly in their analyses to keep even within the acknowledged varying 
limits of human milk. It is therefore high time for physicians to appre- 
ciate exactly how inefficient in themselves and how misleading in their 
claims are these artificial foods, and also in what a false position, as the 
protector of and adviser to the public, our profession is placed whenever it 
lends itself to even a toleration of their use. I speak of them here simply 
because there is no doubt that they are kept in the market by the physi- 
cian rather than by the manufacturer. The latter is only doing what any 
capitalist interested in a business venture would do. The former, it seems 
to me, is, perhaps unintentionally, aiding the business interests of others at 
the expense of his own future reputation as a scientist. It makes little dif- 
ference to physicians as to what is claimed for these foods when they are 
placed in the market. It makes a great difference what the mixture con- 
tains when given by the mother to the infant according to the directions on 
the label. For instance, a food may show by its published and certified 
analysis a fair percentage of fat or sugar, and yet this same food when 
diluted for the infant's feeding may have these constituents reduced far 
below the reasonable limits of nutrition. 

Matzoon. — Matzoon is a fermented milk made by the action of an 
imported ferment, probably a form of yeast, upon cow's milk. The 
milk is first boiled for the purpose of sterilization, the matzoon ferment 
is added, and the fermentation is begun at a temperature of about 40.5° C. 
(105° F.) and continued in an open vessel for twelve hours. The 
temperature is gradually cooled to about 21.1° C. (70° F.) and the milk is 
bottled and kept on ice. It is ready for use in twenty-four hours. If 
used for infant feeding, it should be diluted with water and fed with a 
spoon, as it is too thick to be drawn from a bottle. 

Kumyss. — The best formula for the domestic manufacture of kumyss 
is that described by Holt : Take one quart of fresh milk, half an ounce 
of sugar, two ounces of water, and a piece of fresh yeast-cake half an 
inch square. These materials are put into wired bottles and kept at a 
temperature of 15.5° C. (60° F.) or 21.1° C. (70° F.) for one week, shaking 
five or six times a day. The milk is then put upon the ice until used. 

Malted Foods. — These are obtained by the action of the malt diastase 
upon wheat and barley flour, and are composed of a mixture of dextrine, 
dextrose, and maltose, with a small amount of cane-sugar. 

Matzoon, kumyss, and malted foods, in the light of recent researches 
and advances which have been made in the feeding of infants and children 
with modified milk, may no longer be considered as advisable foods. 



16 



242 ' PEDIATRICS. 

SECOND NUTRITIVE PERIOD. 

During the eleventh and twelfth months of life the amylolytic function 
of the infant has become almost fully developed. In accordance with the 
rule regarding the use of the different functions, — namely, that a function 
should not be taxed before it is developed, but that when its development 
is almost completed it should be brought into use, — we should in the lat- 
ter part of the first year begin to use that function of the digestive tract 
by means of which the amylaceous elements of the food are converted 
into sugar. 

At this age the percentage of sugar should gradually be reduced in the 
modified milk and the percentage of proteids increased until the whole 
milk is found to be digested. The reason for changing the relative percent- 
ages of these elements is that the power to digest proteids has much in- 
creased during the latter part of the first year. The capacity for digesting 
a high percentage of sugar is just as great at this period as at an earlier 
one, but the amount of sugar, given directly as such, in a modified milk, 
which is required in the later is not so great proportionately as in the 
earlier period. A large portion of the sugar which is needed for nutrition 
in this later period is intended to be introduced into the economy by means 
of a new element in the food, — starch. A certain amount of sugar is, as 
before, directly introduced into the gastro-enteric tract from the milk-sugar 
of the milk, and the starch when converted into sugar supplies the re- 
maining portion of sugar needed for nutrition. In a normal infant with 
normal digestive functions a considerable percentage of starch can be di- 
gested and absorbed with benefit in the eleventh and twelfth months. It 
is well, however, at first not to give immediately a high percentage of 
starch in the mixture, and also not to ignore the fact that the various 
cereals contain fat and proteids as well as starch. Consideration must 
also be paid to what the total resulting percentage of sugar will be when 
contributed by the converted starch and the milk-sugar in the milk. In this 
way a gradual change of percentages can be made in the infant's food until 
its digestive capabilities have become adapted to the food values indicated 
for digestion in the second year. This indication is for a higher fat, sugar, 
and proteid percentage in the food and for whole milk, preferably from 
Holstein cows. When, however, the digestion is weak, a modified milk 
can be continued into the second year. 

Any additional sugar which may be needed with the food can at this 
time be in the form of cane-sugar rather than milk-sugar. The starch can 
best be obtained from preparations of oats, barley, and wheat. There is 
a larger percentage of starch in oats than in barley. It is also more nu- 
tritious in every respect, as it contains a considerable percentage of fat. 
The starch in oats takes a somewhat longer time to be converted into 
sugar than does that of barley, so that in the case of an infant whose 
amylolytic function is not fully developed or is somewhat weak, prepa- 



FEEDING. 243 

rations of barley will be better to begin with, because they do not intro- 
duce so high a percentage of starch into the food, and also because the 
starch will be more readily converted into sugar. Preparations of oats 
seem to be the best form of food to be added to the milk when the infant 
has reached a period at which it needs a change in the character of 
its food. 

We have, therefore, in preparations of oats, both for purposes of 
weaning and for establishing a new regimen of diet for the infant, a food 
which in combination with cow's milk satisfies completely the demands 
which the digestive functions at this period are making for a perfect nutri- 
ment. In using cereals in the food they are best at first reduced to a 
jelly, as described on page 239. 

The second nutritive period may be reckoned to last from the twelfth 
to the twenty-eighth or thirtieth month of life. That is about the second 
half of the period which we are in the habit of calling infancy. It also 
includes the time when the last four teeth of the first set appear. In this 
second nutritive period the element of variety in the food becomes impor- 
tant. It is undoubtedly important that the actual nutritive values of the 
food which it is best to give to infants in this period be considered, but it 
is much more important that special attention be paid to its variety. 
Foods should be given which while containing a fair percentage of nutri- 
tive elements yet differ in the combination of these elements to such a 
degree that they fulfil the requirements of this period of life. It is best to 
increase gradually the variety of articles of diet from the twelfth to the 
twentieth month, always adapting the food to the especial infant. Thus, 
some infants may be able to digest and assimilate proportionately large 
quantities of starch ; others may both need and digest larger proportions 
of the proteids or of sugar than the infants first spoken of. 

Between the twelfth and thirteenth months the infant should have 
five meals during the day. At this time it is well to accustom it to take 
its food from a spoon, and as soon as possible to omit feeding from the 
bottle. The five meals should be arranged in the following manner : 

For breakfast, bread and cow's milk, slightly warmed. 

For lunch, equal parts of oat-jelly and cow's milk, warmed, with a 
little salt added according to the infant's taste. 

This meal of oat-jelly should be repeated in the middle of the after- 
noon. 

In the middle of the day, broth of some kind, either chicken or mutton, 
carefully prepared so as to be free from fat on its surface, can be given 
with some bread. 

The fifth meal should be given in the latter part of the afternoon, and 
should consist of bread and milk. 

In some cases it is impossible to make infants swallow bread for a 
long period after the usual time of twelve to thirteen months. At times 
it is not until they are two and one-half to three years old that they can 



244 PEDIATRICS. 

be induced to take bread. In these cases we must feed them according 
to our judgment of the individual case. 

When the infant is fourteen to fifteen months old, some thoroughly 
boiled rice can be added to the broth in the middle of the day, and if it 
digests this well it can also have broth given with this meal. 

When the infant is sixteen months old, it can have a small amount of 
butter on its bread. When it is seventeen to eighteen months old, it can 
have a thoroughly baked white potato, mixed with butter and salt, added 
to its mid-day meal of bread. When it is nineteen to twenty months old, 
eggs can become part of its diet. 

There are not many fruits which should be given to the infant in its 
second year. A baked apple can be given at the evening meal when the 
infant is fourteen to fifteen months old ; or, for variety, the apple can be 
made into a simple sauce, never, however, having the sauce made with 
much sugar. When peaches are in season, a ripe peach can often be 
given with benefit, especially if the infant is inclined to be constipated. 
Other fruits should be avoided, as they are not necessary for the infant's 
nutrition and at times produce serious trouble. 

This is the diet which is sufficient for the infant during the second 
nutritive period. It is important for the subsequent integrity of the in- 
fant's digestion and general nutrition that the parents should insist that no 
other articles of food be employed, except such as are similar to those 
which have been mentioned, — namely, the cereals in a variety of forms, 
according to the taste, judgment, and knowledge of cooking which exists 
in the special household. For instance, preparations of wheat and barley 
cooked in various forms may be given in place of oatmeal. Bread also in 
different forms may be given. The crust of French bread is easily digested, 
and is supposed to have less starch in proportion to its gluten than the 
usual home-made bread. It is well to begin with some form of bread of 
this kind when we are getting the infant accustomed to take starch in the 
form of bread. If it is constipated, Graham bread and preparations of rye 
will also be found useful. Fresh bread should never be given, and bread 
one day old is the preferable form which should be provided. 

The infant should never be given cake or candy even to taste. It is 
necessary to state this very decidedly, because it is an erroneous view 
which is held by most mothers that it can do no harm to give occasionally 
to an infant in its second year of life, or to a young child, a little candy 
or a little cake. This may be true so far as the immediate effect these 
articles may have on the digestion is concerned, but it is of far more im- 
portance that the infant should not have its taste perverted from those 
articles of diet which are best for its nutrition. These new articles appeal 
more strongly to its sense of taste, and allow it to know that there is some- 
thing which tastes more agreeable than the food which it is accustomed to 
have. When an infant has acquired a taste for cake or candy, it will cease 
to enjoy the food by which its development will be best perfected. It is, in 



FEEDING. 245 

fact, kinder to the infant never to allow it to taste cake or candy. When 
these articles are withheld, it will continue to have a healthy appetite and 
taste for necessary and proper articles of food. 

Broths can be prepared in the following manner : 

Chicken Broth and Jelly. — A fowl weighing about three pounds, with 
two tablespoonfuls of rice, two quarts of cold water, and salt and pepper, 
should be boiled for two hours and until the fluid has boiled down to one 
quart. The fluid should be strained while hot through a fine sieve. If a 
jelly is to be made, the broth made in the above manner should be 
allowed to cool in an earthen jar for about twelve hours in the ice-chest. 
The resulting jelly can be used in full strength or diluted with water. 
When the jelly has been thoroughly cooled, the fat can be partially or 
entirely removed from the top. 

Mutton Broth. — A shoulder of lamb, when it can be obtained, — 
otherwise of mutton, — weighing from five to seven pounds, is treated in 
the same way as is the fowl for the preparation of chicken broth. 

THIRD NUTRITIVE PERIOD. 

The third nutritive period I have arbitrarily made to begin at about 
the thirtieth month of life. 

At this time it will be well to begin to accustom the child's digestive 
functions to a still greater variety of food. In summer the more easily 
digestible vegetables, such as squash, young peas, and young beans, can 
be given. The variety of fruits can also be increased at this period, but 
they should be cooked. The principal change which is to be made in the 
diet to which the infant has been accustomed is a very decided increase in 
the proportion of the proteid element of its food. This is accomplished 
by means of giving the child meat. The quantity of meat which should 
be given towards the end of the third year should be small at first, and 
should be given at intervals of a day or two. Meat as a regular article 
of diet for each day is not, as a rule, required until the child is between 
three and four years old. The kinds of meat which should be given in 
this early period of childhood are chicken, mutton-chop, roast beef, and 
beefsteak. These meats should be cut into small pieces, and a little salt 
added according to the child's taste. It is well during the third year to 
give the child an egg on one day and meat on the next. 

When the child has reached the age of five or six years, we should 
allow it to have a somewhat more varied diet, but during the whole 
period of childhood up to the age of puberty the closest attention should 
be given to the regulation of the kind and the amount of food to be 
given to the child, and any deviations from the rules which have just 
been laid down are to be deprecated. 



DIVISION III. 

GENERAL PRINCIPLES OF EXAMINATION AND 

TREATMENT. 



Method of examining a Child. — When a physician is called to see a 
sick child, he must, if possible, ascertain before entering the nursery what 
is the temperament of the child with whom he will have to deal, and by 
the aid of this information regulate the manner in which he approaches it. 

An infant in the early months of life too young to fear a stranger, a 
child of quiet phlegmatic temperament, or one that is too sick to object to 
being handled, can be examined as soon as it is seen, with the regularity 
and precision which one would employ with the adult. 

It is an entirely different task, however, when one is called upon to 
examine children who are nervous, excitable, or timid, or who are spoiled 
and vicious. In dealing with the first and more difficult class of these 
cases much deliberation in the way in which the child is approached is 
needed, and much tact in speaking to it is required. In the second, the 
spoiled and vicious class, time cannot be gained by delaying the examina- 
tion, and the sooner it is made with firmness and persistence the less try- 
ing it will be for the child and for the mother. As a rule, the more the 
child cries and resists needlessly, the less likely is it to have any disease 
of serious import. 

It is wise at first to make the child think that no notice is being taken 
of it. It is well to notice its toys, and to appear to take great interest in 
them and also in the pictures in the nursery. The child very soon will 
become accustomed to the physician's presence, and will begin to take the 
same interest in him that he seems to take in its toys. A nervous, timid 
child will often from this point of the examination allow itself to be ex- 
amined without further trouble. 

The physician, however, should always be gentle both in his voice and 
in his touch, and on the slightest appearance of timidity, or manifestation 
of a desire to avoid him, he should at once stop the special part of the 
examination which he is making, and appear not to take any notice of 
the child. 

All these preliminaries and minute details, which seemingly delay 
the examination, in fact expedite it, since, when once the timid child is 

246 



GENERAL PRINCIPLES OF EXAMINATION AND TREATMENT. 247 

thoroughly frightened, the rest of the examination becomes very unsatis- 
factory, for it is almost cruel in cases of this kind to attempt to force an 
examination, which in the case of the vicious child can be done usually 
without cruelty and without hurting the feelings of the mother. 

The faculty of examining the child when it is crying and excited with 
the same precision as when it is quiescent, though perhaps by a somewhat 
different method, should be acquired. The trained hand and ear can 
detect an abdominal or pleuritic effusion or a solidified lung almost as 
well when the child is screaming as when it is perfectly docile. 

This is an accomplishment which should be mastered at once by every 
practitioner who expects to have children under his care. In fact, if this 
were more universally understood, we should hear less of the impossibility 
of determining what is the matter with a child on account of its being 
fractious. 

As the physical examination of a child is more difficult than that of an 
adult, and needs to be made more quickly, every means should be em- 
ployed which will tend to throw light on the final result. 

History. — A complete history of the case is very valuable, and should 
be obtained from the mother and the nurse, preferably before seeing the 
child, for in this way the physician can obviate asking many questions in 
its presence, a procedure which frequently fatigues it and renders it more 
difficult to examine. It is well to allow the mother and the nurse to tell 
you in their own language what they know about the child and its sick- 
ness. After they have finished, you can easily systematize the history of 
the case by any questions which you may wish to ask. Although the 
history given by the mother and the nurse is usually imperfect and discon- 
nected, yet it is very likely to supply certain important points which you in 
your questions might easily overlook. The mother and the nurse are so 
constantly with the child that they notice all the slight shades of difference 
in its condition from hour to hour, a knowledge of which is of great im- 
portance in obtaining a correct appreciation of the general condition of 
the child, whatever the disease may be. 

The information especially to be elicited is in regard to the health of 
the parents, whether there is an hereditary tendency in the family ; 
whether the mother has had miscarriages (in reference to a possible syph- 
ilis) ; whether there are other children, and, if so, the state of their health ; 
if any have died, of what did they die ; the birth weight of this child ; 
was it nursed, and, if so, for how long ; did it have a substitute food, and, if 
so, of what kind ? Did it gain in weight regularly, and what is its present 
weight ? At what age did it cut its first tooth, and how many has it now ? 
At what age did it sit, and stand, and walk alone ? What diseases has it 
had ? How long has it been sick ? What were the first symptoms ? Its 
appetite ? Its sleep ? Its temper ? The number of its movements in 
twenty-four hours ? The physician should personally inspect the faeces, 
and should, if possible, obtain and examine a specimen of the urine. 



248 PEDIATRICS. 

Having now systematized in his own mind the history of the case, the 
physician on entering the nursery should proceed with his inspection of 
the child. , \ 

Temperature. — It is so important to ascertain what the temperature 
of the child is that, if possible, the temperature should be taken before 
the child has become frightened or fractious. The place for taking the 
temperature should be in the axilla or rectum. The most successful 
method of obtaining it is to explain to the mother and nurse exactly 
what you wish to have done. They should be directed to take the 
thermometer and show it to the child as though it were a toy, to put it 
under the child's arm, and to play with the child until they are told to 
remove the thermometer. A rectal temperature is always desirable when 
it can be obtained, as it is more exact, and is usually at least one degree 
higher than under the arm. As a rule, the temperature cannot be safely 
taken in the mouth in young children. 

Inspection. — One of the most valuable means of making a diagnosis 
of disease in children is the careful inspection of the child before attempt- 
ing to percuss or to auscult it. In fact, when children are irritable and 
restless the inspection becomes of the utmost importance, and an eye 
which has been trained to understand the different aspects of disease in 
children readily makes the diagnosis in many cases without further assist- 
ance. A rule to be remembered, and one which will be found of great 
practical value, is, if possible, to have the child entirely undressed, so that 
we may see the whole surface of the skin in front and behind. Not only 
shall we thus be able to recognize the symptoms attributable to a simple 
irritation of the skin, whereas otherwise we might be led to consider 
them as representing a more general and constitutional disturbance, but 
the skin will also be found to be a valuable index by which to judge of 
diseases of the other organs. The cyanosis which so frequently represents 
some disturbance in the heart or lung, the quick respirations of either a 
thoracic or an abdominal type, a sunken or a distended abdomen, and the 
position of the child, all point towards symptoms belonging to special dis- 
eases. By means of all these symptoms, which can be seen at a glance, 
the diagnosis of the special disease can, after considerable experience, 
usually be made without much aid from other sources. 

Respiration. — Either when the thermometer is under the child's arm 
or when the regular inspection is begun, the rate and rhythm of the res- 
piration can be determined. Having determined the temperature and 
respiration, if all that is necessary about the child when it is quiescent 
has been seen, the physical examination should next be made. 

Palpation. — Palpation is a very valuable means of diagnosticating 
disease in children, whether it be of the abdomen or of the thorax. It is 
well to begin with an attempt to take the pulse. Sometimes this can be 
readily accomplished. At other times it is impossible, and, as a rule, I 
rely less on the rapidity of the pulse in the child than on the information 



GENERAL PRINCIPLES OF EXAMINATION AND TREATMENT. 249 

which is received from the temperature and respiration. It takes so little 
to increase the rate of the pulse in a young child that if we were to 
judge in every case by it Ave should often be misled in our diagnosis. 
What we wish especially to learn is whether there is a slow pulse or 
whether it intermits. This we can usually ascertain by keeping our 
finger for a few seconds on the child's radial artery. When we have 
once obtained a fair idea of the rate and rhythm of the pulse we can 
proceed with the remainder of our examination by palpation. 

A young child's thoracic walls are so thin, and vibration is so pro- 
nounced in them, that often we can detect what process is going on in the 
lung by merely putting our hand on the chest, and we can feel in a chronic 
bronchitis what will prove on auscultation to be coarse sonorous rales. We 
can also sometimes feel a pleuritic or a pericardial friction-rub, and fre- 
quently a roughening of one of the valves of the heart. It is not alto- 
gether impossible in certain cases to distinguish the difference presented 
to the hand between a pleuritic effusion and a solidified lung. The ex- 
amination of the abdomen, even when the child is crying, can be ac- 
complished with considerable precision. Waiting until the child stops 
crying for a second and relaxes its abdominal walls, by firm but gentle 
pressure the abdominal walls can be depressed so as to obtain a fair 
knowledge of whether an abdominal tumor is present. Fluid in the ab- 
dominal cavity can also readily be detected by palpation. 

A rectal examination is often important in infants and young children. 
It can readily be made without hurting the child, and the fmger is able 
to reach much farther proportionately into the child's pelvis than into 
that of the adult, and very much more can be learned by this method 
than in adult cases. An invagination or an appendicitis can be diagnosti- 
cated by the combined examination through the rectum and by external 
pressure when external palpation alone has failed to give evidence of 
disease. 

In the infant the head should be carefully examined in reference to 
the fontanelles. Measurements should be taken of the head and of the 
thorax. 

At this stage of the examination we shall have determined almost 
always what disease is affecting the child, but every known method should, 
of course, be made use of for verifying the diagnosis. We should, there- 
fore, endeavor to percuss and auscult the child, but in a somewhat dif- 
erent way from that which would naturally be employed in the adult. 
The louder the child cries, the easier is it to obtain evidence, through 
vocal fremitus, of the nature of the disturbance in the chest. 

Percussion. — Even when the child is crying and resisting, percussion 
may be of the greatest importance. Light percussion, as a rule, is prefer- 
able to the deeper and heavier percussion. The chest walls are so reso- 
nant that deep percussion rather masks the process which is directly under 
the finger by bringing out sounds from all parts of the chest. Direct per- 



250 PEDIATRICS. 

cussion with the finger is preferable to the use of any instrument, as in 
this way both palpation and percussion may be combined. Palpatory per- 
cussion in my hands has always proved exceedingly valuable for purposes 
of diagnosis. A few light taps over the normal boundaries of the '-heart 
and lung will give much information, even though it may be impossible 
to obtain a more extended percussion of the chest. If the child is crying, 
one should watch until it takes its breath ; just as it inspires it necessarily 
stops crying, and at that moment a perfectly clear percussion note can be 
obtained. 

Care should be taken not to make the physical examination too pro- 
tracted. Rapidity, both in palpation and in percussion, is very important, 
and a young child should be examined with much greater rapidity than is 
usual or necessary in the case of an adult. Much more information will 
be obtained in this way than if the child is wearied by continual efforts to 
make sure that no mistake has been made. 

The sounds which can be elicited from a young child's chest are so 
varied that it is more difficult to differentiate them than in the adult. If 
one hesitates and doubts one will not arrive at as correct a result in the 
examination as when the mind is trained to grasp at once the salient points 
in the special physical examination, and to depend somewhat more on the 
first idea which is formed than would be wise in the older cases. 

Auscultation.— I have noticed that children are much more sensitive 
to the feeling of the stethoscope than are adults. In many cases they 
shrink from it as though it hurt them, even when they have not been 
frightened by the previous part of the examination with palpation and per- 
cussion. It is, therefore, exceedingly important to make the examination 
as pleasant to the child as possible. A rubber cup applied to the end of 
the stethoscope serves this purpose well. The feeling of the soft rubber 
is pleasant to the child, and it conveys the sound with almost as much 
clearness as does the hard rubber end of the stethoscope. The stetho- 
scope should have flexible rubber arms so as to follow easily the motions 
of the child, and its bell should be of such small caliber that it can easily 
be introduced between the ribs of even a young child. 

In like manner a phonendoscope with a small disk, such as is repre- 
sented in Fig. 58 is valuable where the sounds of the lungs or heart are 
very feeble, or when it is found preferable to examine without having all 
the clothes removed. 

It is, however, often of great aid in the proper appreciation of the 
sounds which are heard with the stethoscope in infants and in young chil- 
dren, especially when they are crying, to use a stethoscope which does not 
convey the sound so clearly and intensely as do others. We can often in 
this way differentiate a soft cardiac murmur which if a more delicate in- 
strument were used would be entirely obscured by the loud sounds coming 
from the trachea and bronchi of a crying or screaming child. We can, 
also, often distinguish the fine rales of a broncho-pneumonia in contradis- 



GENERAL PRINCIPLES OF EXAMINATION AND TREATMENT. 



251 



tinction to the loud coarse rales which tend to obscure the other sounds 
in the chest. 

Examination of the Throat. — The examination of the throat should 
be left until we have practically finished with the general examination of 
the child, because, as a rule, it is the procedure of all others which irri- 
tates it, and after we have once attempted to examine the throat we shall 



Fig. 58. 



Fig. 59. 



Phonendoscope. Reduced two-fifths. 



Tongue depressor. Reduced 56 per cent. 



seldom be forgiven by the child at that special visit. Some children will 
allow you to look into their throats without being at all disturbed. As a 
rule, however, it frightens them, and we should use the most gentle and 
rapid methods for accomplishing our purpose. We must not expect to be 
able to sit down in front of the child and examine its throat for some 
minutes, as is possible with adults. We must adopt some definite method 
by which we can control the child and catch a glimpse of the mouth, 
tongue, and pharynx. The more quickly we do this, the less it frightens 
the child, and it is important that we should not make extensive prepara- 
tions which it will notice and which will indicate what we are going to do. 
The mothers are often much disturbed by seeing the child first frightened 
with the idea that it is going to have a spoon put in its mouth, and then, 
while screaming and crying, forced to the window and compelled to open 



252 PEDIATRICS. 

its mouth. It is far better under all circumstances to tell the mother and 
the nurse what to do, and for us not to go near the child until they are en- 
tirely prepared to control its limbs and are holding it in a position in 'which 
it is practically helpless. It frightens the child much less to have it sit in 
the nurse's lap with its face to the window than to examine it on its back. 

The nurse should hold the child firmly against her chest, so that it 
cannot move its arms or legs or slip from her lap. The physician should 
control the child's head with one hand while with the other he gently in- 
troduces the handle of a spoon into the mouth, passing it back until it 
touches the soft palate, when the child will gag, and a quick glance can be 
obtained of the tonsils and pharynx. 

I prefer to use a spoon for examining the throat, because in every 
household one may be easily obtained, and it obviates the use of the 
same instrument in a number of mouths, which is something to be con- 
sidered in children, in whom infection by the mouth is so common. Of 
course, for those who prefer to use the usual tongue-depressor the danger 
is reduced to a minimum if a careful disinfection of the instrument is made 
after it is used ; but in the case of infants, who should also be examined 
in an upright position, the spoon is decidedly preferable, because the neck 
of the infant is so short that its chin is in close proximity to its chest, and 
the handle of the tongue-depressor interferes with the proper downward 
pressure of the instrument. The spoon-handle, on the other hand, is. 
exactly the shape which is best adapted to the infant's mouth and tongue, 
and the spoon, being comparatively straight, does not encroach upon the- 
thorax when the downward pressure is made. 

Fig. 59 represents a tongue-depressor devised by Dr. Henry Chapin, 
of New York, and is remarkably well suited for the examination of the 
infant's throat, as the curve is adapted to that of the tongue. 

The Throat. — The throat of the child may often be affected, and be the 
only source of the symptoms, although these symptoms may not be what 
one would expect to find associated with a lesion in this region. Young- 
children are so apt not to complain of their throat, and to show merely 
signs of general constitutional disturbance, that the physician is very likely to 
be misled and to overlook the real seat of the disease unless he makes it a 
rule always to examine the throat at his first visit and in all obscure cases. 

Inspection of the Mouth. — It is well when the physician is examining 
the throat of an infant in the first two years of its life, and even later if 
there are any symptoms which point towards the mouth, to examine the 
gums carefully. The hands should be carefully washed before intro- 
ducing the fingers into the mouth. This is in accordance with the 
common rules of cleanliness, and also is required in order that the intro- 
duction of pathogenic organisms into the infant's mouth should be avoided. 
In examining the gums we judge whether they are swollen or reddened, 
dry, moist, or hotter than normal, and also whether there is a condition 
of the gums which indicates the use of the lancet. 



GENERAL PRINCIPLES OF EXAMINATION AND TREATMENT. 253 

, Examination of the Ears. — One of the most important means of rightly 
interpreting the symptoms of restlessness, of evident pain, of heightened 
temperature, of undue somnolence, as well as a great many other symp- 
toms, is the examination of the ears of infants and of young children. A 
slight irritation in the throat may at times cause a congestion in the vessels 
of the membrana tympani which may produce all these symptoms. 

It is, therefore, very important, unless you are sure that the symptoms 
do not arise from some condition in the ear, that you should examine the 
ears at some time during your visit, choosing that time which seems most 
favorable in the especial case. A thorough knowledge of the possible 
symptoms which may arise from the ear is of the very greatest impor- 
tance for the general practitioner to possess. 

Lumbar Puncture. — Paracentesis of the vertebral canal is of great aid 
in certain cases. This procedure is employed for diagnosis in obscure 
cerebral disease, and enables us to determine, first, whether a meningitis 
is present, and second, whether it is a form of tubercular, non-tubercular, 
or cerebro-spinal meningitis. 

Rontgen Light. — The X-ray has been used more extensively and suc- 
cessfully in surgical cases than in medical, and its use for medical cases in 
children has so far been rather limited. As in diseases of the heart and 
lungs it is not only their size but their movements which we wish to 
observe, the fluoroscope is better adapted for detecting pathological con- 
ditions. Examination with this instrument can also be made more 
quickly than with the radiograph, which requires more time to develop, 
but gives more details of those organs which are at rest. An example 
of the extent to which radiography is applicable for showing the outlines 
of the different organs, even when they are moving, can be seen in Plate 
IV., facing page 254, which represents the thorax and abdomen, Avith 
their contents, of a child of six months. 

It is now claimed that with the fluoroscope thoracic and pericardial 
effusions, even when small, can be detected ; also that a central pneu- 
monia can be recognized before there are any signs on auscultation and 
percussion, and that the area of consolidation of a pulmonary tubercu- 
losis can be diagnosticated by the diseased area of the lung appearing 
darker than normal, and by the restriction of the excursion of the dia- 
phragm in quiet breathing and in full inspiration. An enlarged heart or 
a transposed heart can also be detected with the fluoroscope. The X-ray 
photograph reveals changes in the bones, such as occur in rhachitis (Plate 
V., facing page 336) : in tuberculosis (Plate VII., facing page 512) ; in osteo- 
myelitis (Plate VII., facing page 512) ; in syphilis (Plate V., facing page 
336) : and also changes in the various abdominal organs. Radiography 
is therefore probably destined to become a very important aid in our 
diagnosis in the diseases of children, and should always, if possible, be 
used in obscure cases, such as we are continually meeting with, especially 
in the lung in which a central pneumonia may be masked for many days, 



254 PEDIATRICS. 

and yet the child be so ill as to cause the most serious apprehensions #as 
to diagnosis and prognosis. 

Treatment in General. — The treatment of infants and children con- 
sists largely in the administration of a food adapted to the condition of 
the child, and in gradually changing from a weak food to a strong one, or 
vice versa, according to the especial indications in the disease as it runs 
its course. Of great importance also is the regulation of the temperature 
and the purity of the air in the sick-room. In many cases, especially in 
the first year of life, a change from one room to another several times 
during the day is advantageous, and the room should be as large as possi- 
ble. The application of cold and heat by sponging and baths, and the 
technique of gavage, lavage, and intestinal irrigation, will be spoken of in 
describing the treatment of the various diseases in which they are indi- 
cated. 

Stimulants, if used with good judgment and given as described in the 
treatment of the various diseases, are very valuable, and are called for 
not only in cases of sudden collapse, in which their administration by sub- 
cutaneous injection is indicated, but whenever there is depression with a 
weak or intermittent pulse, as in diphtheria, at times in typhoid fever, 
and also where there is a sudden fall in temperature, as is frequently seen 
at the crisis of a pneumonia. The amount of the stimulant for the espe- 
cial age cannot be given, as it depends entirely on the disease and the 
condition of the especial patient. The form of stimulant which is borne 
best by young children is brandy or whiskey. The contra-indications for 
stimulants are found in those cases in which the child has a hot, dry skin, 
flushed face, and a full, regular, and tense pulse. Great caution should 
be used in the administration of stimulants, as there is no doubt that 
they are given with but little judgment in many cases, and that to obtain 
the best results they should be reserved for cases in which they are clearly 
indicated. They should be given in rather small doses, the larger doses 
being reserved for special conditions. As a rule, the average practitioner 
gives much larger doses of stimulants than are needed. 

Especial attention should be drawn to the fact that the younger the 
infant the greater is the importance of keeping the nasal passages clear, 
irrespective of the disease. The infant responds much more quickly to 
treatment if its vitality is not lowered by its efforts to breathe through its 
mouth rather than through the natural passages. A spray of oil is the 
treatment in young children for occluded nares. Nasal irrigation is de- 
scribed under the treatment of diphtheria on page 473 ; enemata on page 
830, and atomization of the throat and larynx on page 655. 

An important fact to remember in the treatment of infants and young 
children is that drugs play a very insignificant part in the actual cure of 
diseases. According to my observation, numbers of children are being 
treated by drugs, and yet often, so far as I can see, this time-honored 
means of satisfying parental prejudices is but prolonging the symptoms of 



PLATE IV 




Infant, 6 months old. Taken under chloroform from behind. Stomach and large intestine dis- 
tended with gas. 1, right lung ; 2. left lung ; 3, heart ; 4, liver ; 5, stomach ; 6, left kidney ; 7, right 
kidney ; S, ascending colon ; 9. descending colon ; 10, probably the head of the pancreas. 



GENERAL PRINCIPLES OF EXAMINATION AND TREATMENT. 255 

a disease which, self-limited, has run its course. I do not for a moment 
question the direct benefit obtained from quinine in malaria and mercury 
in syphilis : it is the promiscuous use of drugs in every case of sickness to 
which I am especially opposed, for in many cases the child will recover with 
equal or even greater rapidity without them. 

Instances probably arise in the practice of every physician in which he 
feels that the drugs which have been given have either directly harmed the 
child or, by disturbing its digestion and thus interfering with its nutrition, 
have indirectly produced more serious symptoms than those presented by 
the original disease. The greatest caution should be employed when drugs 
are used with young children, and there should be a thorough understand- 
ing of their action during the various periods of development. The well- 
known susceptibilty of children to the action of opium and its alkaloids 
should make us careful to begin with minimum doses when it is necessary 
to use this drug. In like manner, although it is traditional that children 
have a great tolerance for belladonna and arsenic, we must allow T that an 
overdose of the former, although not usually fatal, may certainly produce 
most alarming symptoms, while the administration of the latter as I have 
seen it given in the treatment of chorea has in a number of cases produced 
a multiple neuritis. 

The treatment of diseases by special drugs because these drugs have 
been given in the past, because their administration has apparently done no 
harm, or because no new or better remedy has been found, rests upon a 
lack of comprehension of what treatment really means. 

The custom of combining many drugs in one prescription is fallacious, 
and should be discountenanced, especially when infants and young chil- 
dren are being treated. A single drug given in the smallest dose which will 
accomplish its purpose, and in the most agreeable form which is compat- 
ible with the function of digestion, will produce the best results in any given 
disease. 

The delicate skin of infants and young children is peculiarly sensitive 
to reflex disturbances caused by drugs in the gastro-enteric tract, and there- 
fore we must be careful not to mistake the appearances produced by such 
reflex irritation for the various lesions of the skin which may occur in a 
specific disease. Thus, the similarity of the efflorescence produced by 
belladonna to that accompanying scarlet fever is striking. Almost any 
drug, as well as certain articles of diet, may in some individuals produce 
forms of papular erythema, resembling very closely some of the dermal 
lesions of syphilis. It is therefore wise to avoid these possible disturb- 
ances of nutrition by giving drugs only when they are actually known to 
be necessary, and by omitting them as soon as possible. 

It has always seemed to me irrational to prescribe syrups as a men- 
struum for the administration of drugs to children. Their well-known 
tendency to fermentation is sufficient to stamp them as unfit for the treat- 
ment of a period of life when the undeveloped condition of the digestive 



256 PEDIATRICS. 

function indicates the vital importance of protecting this function in every 
way. 

Each case must be treated according to its special pathological lesiqn or 
specific micro-organism. As year by year we are discovering the organ- 
isms which cause special diseases, so the treatment of the future will be the 
actual destruction and speedy elimination of these organisms while sup- 
porting the strength until such elimination has been accomplished. When 
no known organisms exist, the treatment should be if possible to remove 
the cause, and to support the vitality until natural processes have healed 
the special lesion, produced either by exposure or by trauma. 

Prophylaxis. — At no period of life is the prophylaxis of disease so 
important and its results so brilliant as in infancy and early childhood. 
When physicians have sufficiently recognized the fact that disease in young 
children results in the vast majority of cases from a disregard of the laws 
of hygiene and of rational methods of feeding, they will so impress upon 
the laity the true meaning of infantile prophylaxis that the mortality rate 
will be greatly reduced. 



DIVISION IV. 

PREMATURE INFANTS. 



A premature infant is one which is born prior to the usual two hun- 
dred and eighty days which represent the normal duration of intra- 
uterine life. 

Very few cases are reported, and none of them appear to be abso- 
lutely authentic, in which an infant has survived which was born much 
before the twenty-seventh or twenty-eighth week of intra-uterine life. 
The premature infant in its intra-uterine development is unprepared to 
meet the conditions of extra-uterine life, and often dies within a few days, 
and usually within a few hours. 

DETERMINATION OF AGE. — A sufficient number of careful in- 
vestigations regarding the characteristic appearances and the development 
of the foetus during the last four months of intra-uterine life has not yet 
been made and recorded to enable us to state definitely what age the 
infant represents when it is born. The few facts which we possess con- 
cerning this subject must, however, be made use of, and, though not ab- 
solutely correct, are sufficiently so to be of great value to us in our man- 
agement of these cases. One reason for the difficulty which arises in every 
case in determining the age of the foetus is that the conditions which 
influence its growth during intra-uterine life are very varied. The health 
of the mother and her hygienic surroundings, together with the influence 
of heredity on the size of her offspring, present good reasons for decided 
variations in the growth of the foetus in different cases at the same period 
of intra-uterine life. 

If the infant is living when it is born, we should at once carry out the 
rules for preserving its life which have proved to be best in the case of any 
infant born prematurely. These rules should be insisted on even if the 
infant has been born at a much earlier stage of development than is, ac- 
cording to our present ideas, compatible with its viability. This is neces- 
sary, because so many errors in our calculation as to when the impregna- 
tion took place are liable to arise, and also because a foetus may have 
arrived at a period of intra-uterine development which is perfectly com- 
patible with life, and yet from its small weight and general characteristics 
have the appearance of one whose development is incompatible. What- 
ever advances we may make in the future in preserving the lives of pre- 

17 257 



258 PEDIATRICS. 

mature infants born at an earlier date than is supposed to be compatible 

with life, — namely, from the twenty-fourth to the twenty-eighth week, 

it would hardly be practical at this time to discuss the treatment of infants 
born before the twenty-fourth week. 

At Twenty-four Weeks. — A foetus born at about the twenty-fourth 
week of intra-uterine life usually breathes feebly, and dies in the course of 
a few hours, apparently from an inability to accommodate itself to condi- 
tions for which it is not prepared. At this stage of development it may 
still have fine hair (lanugo) over the whole of its body, but it is often the 
case that this hair, commonly found from the sixteenth to the twentieth 
week has disappeared. At this age it still has very little deposition of 
fat in the subcutaneous cellular tissue, and it has a decidedly emaciated 
appearance. In other respects, except in size, it does not differ very 
much in its appearance from the foetus of some weeks' later development. 
Its eyelids have separated, though it is so feeble that, as a rule, it cannot 
open and shut them. 

The estimation of the length of the foetus is difficult to make, and, on 
the whole, unsatisfactory and inexact. These measurements, in all prob- 
ability, differ very much when made by different investigators, owing, as 
Minot has pointed out, to the many changes in the curvature of the longi- 
tudinal axis of the human embryo, which make it impracticable to employ 
any one system of measurement in obtaining comparable results for all 
ages. Hecker's figures, however, are probably as reliable as any we know 
of. According to this author, at about the twenty-fourth week the foetus 
measures 28 to 34 cm. (11 J to 13 J inches). Its weight, according to 
Lusk, is about 690 grammes (23 ounces). 

At Twenty-eight Weeks. — By the time the foetus has reached the 
twenty-eighth to the twenty-ninth week of intra-uterine existence its con- 
dition, so far as its development is concerned, is such that there is no 
necessary contra-indication to its living if it happens to be born at this 
time. It has been stated that an infant born prematurely at the twenty- 
eighth week is more likely to live than one which is born at the thirty- 
second week of intra-uterine life, and that this has been proved by sta- 
tistics. If true, the reason for this, I believe, is because much greater 
care is taken of the former than of the latter. It is reasonable to believe 
that an earlier stage of intra-uterine development is less likely to insure 
continuance of life after premature birth than a later stage, provided the 
same precautions are taken in each case. 

Hecker's and Lusk's figures, in a general way, state that when the 
foetus is born at about the twenty-eighth to the twenty-ninth week it meas- 
ures from 35 to 38 cm. (about 13| to 15 inches) and weighs about 1170' 
grammes (39 ounces). The skin is still wrinkled, is of a dull red color, 
is covered with vernix caseosa, and there is very little deposition of sub- 
cutaneous fat. The infant can move its limbs slightly, cries feebly, and 
often dies in a few hours or days. 



PREMATURE INFANTS. 259 

At Thirty-two Weeks. — Again, using Hecker's and Lusk's figures for 
the thirty-second, thirty-sixth, and thirty-eighth weeks, at about the thirty- 
second week of intra- uterine life the fcetus measures from 39 to 41 cm. 
(about 15J to 16f inches) and weighs about 1560 grammes (52 ounces). 
The hair of the head by this time has increased in thickness, and the 
lanugo, which in many cases is pronounced from the twenty-eighth to the 
thirty-second week, has either begun to disappear or has entirely disap- 
peared from the face. The nails, which between the twenty-eighth and 
thirty-second weeks are often not well developed, now present a normal 
appearance, though they frequently do not quite reach the tips of the fin- 
gers. At this age, also, in boys, it is often possible to feel the testicle in 
the scrotum. There is usually, also, in a healthy foetus, considerable depo- 
sition of subcutaneous fat, and the senile aspect of the earlier periods of 
intra-uterine life is much lessened. 

At Thirty-six Weeks. — At about the thirty-sixth week the length of 
the fcetus is from 42 to 44 cm. (about 16| to 17 J inches) and its weight is 
about 1920 grammes (64 ounces). The lanugo has usually at this period 
disappeared, and the infant, although less energetic than at full term, is 
decidedly stronger than in the previous periods which have been men- 
tioned. It sleeps a great deal, and is still in a condition to die easily un- 
less carefully looked after. 

At Thirty-eight Weeks. — At about the thirty-eighth week of intra- 
uterine life the infant measures about 45 to 47 cm. (about 17f to 18} 
inches) and weighs about 2310 grammes (77 ounces). 

NORMAL DEVELOPMENT. — There have been so few observations 
recorded of the development of the various parts of the fcetus in the latter 
months of intra-uterine life that I am not prepared to describe systemati- 
cally the development of the premature infant as I have already done that 
of the infant at term. There are, however, certain facts which I have 
observed and others which have been recorded. 

Head, Thorax, and Abdomen. — All those anatomical conditions which 
have been emphasized in describing the infant at term as being especially 
prominent are still more marked in the premature infant. Thus, the head 
is large in comparison with the thorax, and the abdomen is in almost every 
case much distended in premature infants, owing to the large propor- 
tionate size of the liver. This distention of the abdomen lasts for many 
weeks, and even months, and its gradual return to the normal size and 
appearance is one of the signs that the infant is doing well and is gradually 
acquiring the normal anatomical development of the infant born at term. 

Skin. — The various changes in the color of the skin, already described 
as represented by erythema neonatorum and icterus neonatorum, I have 
noticed to occur in the premature infant as they do in the infant at term. 

Sweat-Glands. — The function of the sweat-glands is, as a rule, not 
developed at birth, and we do not expect the premature infant in the early 
weeks of life to perspire. There is, however, a great variation as to the 



260 



PEDIATRICS. 



time of the development of the function of the sweat-glands. In an infant 
premature at seven and one-half months I have noticed free perspiration 
take place after it had been born one week. 

Feet. — Some dissections made by Dane on the feet of an infant pre- 
mature at the seventh month show that the foot at this stage of develop- 
ment closely approaches in external appearances the well-developed foot 
of the adult. The dissections also show a remarkably well-constructed 
bony framework. 

Gastric Capacity. — As the question of the proper amount of food to 
be given to a premature infant is of the utmost importance, it is well to 
know about what the average gastric capacity of the foetus is during the 
later months of intra-uterine life. No series of complete and reliable ob- 
servations on this point have been made, that I know of, and the rules 
by which we are guided must for the present be very general ones. The 
less the weight of the infant, the less, in many cases, is the gastric capacity. 

The following figures represent the foetal stomach at four and one-half, seven and 
one-half, and eight months. Fig. 60 represents the stomach at four and one-half 



Fig. 60. 



Fig. 61. 





Foetal stomach (natural 
size) , 4% months old. 



Foetal stomach (natural size) , 7% months old. Weight 
of foetus, 1920 grammes. Gastric capacity, 18 c.c. 



months, and is interesting merely as showing the relatively advanced development of 
the lesser and greater curvatures at this age, as well as the rapid growth which takes 
place between the fourth and the seventh month. 



Fig. 62 



Foetal stomach (natural size 




Weight of foetus, 1230 grammes. Gastric capacity, 22 c.c. 



The next stomach (Fig. 61) was taken from an infant born prematurely at about the 
twenty-ninth to the thirtieth week. It is of rather peculiar shape. The weight of this 



PREMATURE INFANTS. 261 

foetus was 1920 grammes (about 4 pounds). Its gastric capacity was 18 c.c. (about 4£ 
drachms). 

The next stomach (Fig. 62) was taken at about the thirty-second week from a 
fetus which died in forty-five minutes from the time of its birth. The gastric capacity 
was 22 c.c. (5£ drachms). The weight of this infant was 1230 grammes (2 pounds 
9 ounces). 

Fig. 63. 




Foetal stomach (natural size), 8 months old. Weight of foetus, 1440 grammes. Gastric capacity, 8 c.c. 

The next stomach (Fig. 63) was taken from a foetus born at about the thirty-second 
week of intra-uterine life, and weighing 1440 grammes (about 3 pounds). Its gastric 
capacity was 8 c.c. (about 2 drachms). 

Intestinal Contents. — The meconium in premature infants presents 
the same appearance as is seen in infants at term. When the food is 
properly regulated, the faecal discharges assume the consistency and color 
which are seen in those of infants who have been born at term. This 
color in its usual varieties is well represented in Plate III., 6, 7, 8, 9, 
facing page 84. 

Amylolytic Function. — The amylolytic function of the infant at term 
is so slightly developed that we may safely assume that it should not be 
depended upon for the digestion of starch in the premature infant under 
any circumstances. 

Sugar. — Although we must assume that the function of absorbing 
sugar is not developed to the same extent in the premature infant as in 
the infant at term, yet, in all probability, it is more highly developed than 
the other functions of digestion. Sugar is needed to keep up the animal 
heat of the premature infant, which is so very much more readily lessened 
than in the infant at term. Sugar, therefore, is an important element in 
the premature infant's food, but should be given at first in a much 
lower percentage than later, when the equilibrium of the gastro-enteric 
tract has been acquired. 

Fat and Proteid Digestion. — The function of digesting fats and proteids 
is in a much more undeveloped condition in the premature infant than in 
the infant born at term, and should, therefore, not be depended upon to 
the same degree as can safely be done in arranging the food for the older 
infant. Much smaller percentages of these elements should be given to 
the premature infant than to the infant at term, both for purposes of di- 
gestion and of absorption, for, in all probability, the power of absorption 



262 PEDIATRICS. 

of the gastro-enteric tract in premature infants is in a very undeveloped 
condition. As small a percentage of caseinogen in the total proteid as 
possible should be given. 

Kidney. — We should expect, from the lack of development of the 
kidney in premature infants, to find a considerable deposit of uric acid, 
such as has already been described as appearing in the early days of life 
in infants at term. (Plate III., 1, facing page 84.) This is, in fact, the 
case, and the appearance of uric acid on the napkins of premature infants 
is, therefore, not necessarily to be looked upon as denoting an abnormal 
condition. It should, however, be carefully watched, for when it becomes 
excessive it is an indication that the infant's food has not been properly 
adjusted to its digestive powers and that the infant may soon begin to fail. 

Circulation. — The heart in premature infants has not yet arrived at 
the complete stage of development needed to render it a reliable central 
force which can fulfil the demands that will be made on it in the external 
world to sustain the equilibrium of the circulation. Therefore as little 
work as is possible should be thrown upon the heart, and the infant 
should be kept quiet, and not be carried about, as is customary with 
infants born at term. In a number of cases which I have carefully ex- 
amined I have failed to detect a cardiac murmur, which leads me to think 
that the foramen ovale closes soon after birth in the same manner as it 
does in the infant at term. 

Animal Heat. — The animal heat of the premature infant is much more 
easily reduced, and is even more important to its vitality, than it is in 
the infant at term. Following the rule that the smaller the size of the 
human being the greater proportionately is the entire surface, and, there- 
fore, the greater the opportunity for lowering its temperature, an atmos- 
phere which is suitable for the infant at term is too cold for the premature 
infant. 

Premature infants should be thoroughly protected from changes of 
temperature of the atmosphere in which they live, and this temperature 
should be raised to a point which will correspond in some degree to that 
of intra-uterine life. 

Am. — Just as a necessity exists for the premature infant to live for 
some weeks in an atmosphere in which the air approaches in its tempera- 
ture the warmth which exists in intra-uterine life, so is it almost to the 
same degree important that the air which it breathes should be free from 
dust and micro-organisms. The lung is in a very undeveloped condition, 
and although it may be sufficiently developed to carry on the function 
required of it in extra-uterine life, yet all its tissues are exceedingly sensi- 
tive, as are those of the nose and the naso-pharynx through which the 
air must be introduced to the lungs. The air of the ordinary room in 
which infants live when they are born necessarily contains many impuri- 
ties, both irritating and morbid. This irritation of the respiratory passages 
may of itself be sufficient to reduce the vitality of the infant beyond the 



PREMATURE INFANTS. 263 

limits of life. In addition to this, as the mucous membranes of the pre- 
mature infant are not fully developed, the infant is more vulnerable to the 
invasion of pathogenic organisms than at a later period. 

Touch. — Premature infants have to be carefully handled, as they die 
easily from influences which would have little or no effect upon the 
infant born at term. In intra-uterine life they are floating in a fluid which 
practically prevents what in the external world corresponds to handling. 
While they are living in the amniotic fluid they are almost completely 
protected from the influence of touch, which necessarily affects them as 
soon as they are born. Touch, then, is an important element, to be 
avoided as much as possible when the premature infant is born, as it has 
a decided tendency to lower the vitality. 

An instance of the care which is needed to preserve the lives of these 
infants came to my notice in the case of an infant premature at eight 
months which was in my service at the City Hospital. 

During the first week or ten days of its life this infant was in charge of an un- 
usually careful and experienced nurse, who appreciated the risk of handling it. It was 
gaining in weight and was doing well ; but unfortunately another nurse was substi- 
tuted who did not understand this class of infants so well. She allowed the patients 
in the ward to handle the infant, to talk to it, and to surround it with various similar 
deleterious influences. For a few days it lost in weight, and then it suddenly died. 
There is no doubt that it was unable to withstand the amount of handling, which would 
have done no harm to an older infant. 

Light. — The premature infant should live in comparative darkness 
during the early weeks of its life. Light is not requisite for the develop- 
ment of the infant in the earlier stages of its existence, and too much light 
will impair its vitality. It is important to adapt the light to the stage of 
its development, and gradually to accustom it to more light as it grows 
older. 

Souxd. — In the normal intra-uterine conditions the infant is very 
slightly exposed to sound, and all its functions are adapted to silence 
rather than to the many noises which unavoidably surround it in the ex- 
ternal world. We should therefore so arrange that from the minute it is 
born it is protected from noise. 

Pulse, Temperature, and Respiratiox. — I have not very exact records 
of the average pulse, temperature, and respiration found in premature 
infants. These infants seem to present rather irregular types of temper- 
ature and pulse, as well as of respiration. They have to be so carefully 
handled that observations as to these physical signs must be made with 
great caution. The main point in regard to these three conditions of the 
premature infant is that they are all represented by irregularity. The tem- 
p&rature of the premature infant, when it has once begun to gain in weight 
and to thrive, is usually a little above the normal temperature of the infant 
at term. Before it has begun to gain in weight and when its vitality is 



264 PEDIATRICS. 

much depressed, the temperature, as would naturally be expected, is rather 
below the normal standard ; and we should watch this sign with the great- 
est solicitude, as a decided and continuous depression is often indicative 
of approaching death. The pulse is difficult to take in the premature 
infant, and, as a rule, is somewhat quicker than in the infant at term. 
The respirations, irregular in the infant at term, are still more irregular in 
the premature infant, at times being rapid for a few seconds, and then 
becoming almost imperceptible for some minutes. 

APPEARANCE AT BIRTH. — The picture of a premature infant in 
the early days of life is quite characteristic. Besides its very small size, 
as shown in Fig. 64, where the size is compared with the nurse's hand, 

Fig. 64. 




ft;;:,;„;„-:,;,^ — — — ..,,,; ■ , .. - .. — . : ^ .i ; ;,■;:„, ,- - __^ 

Infant premature at seventh month. Birth-weight, 1740 grammes. Age, 10 days ; weight, 1540 grammes. 



it shows in varying degrees an absence of the life and vigor which is 
seen in the fully developed infant at term. It is emaciated, its skin being 
soft, wrinkled, and showing very little subcutaneous fat. Its head is 
large, its abdomen broad and distended, and its limbs puny. According 
to the stage of its development it may or may not have the remains of the 
hair (lanugo) on its body which was present in uterine life, and in like 
manner its nails may or may not be well formed. Its face has a senile 
expression and it is torpid and extremely somnolent. The eyes are 
closed. Its cry is very feeble. The surface temperature is usually cool, 
the extremities seldom move. The respirations are very superficial and 
irregular, often ceasing altogether for a few seconds. The power to suck 
and even to swallow is often slight. These signs evidently indicate that 
the vitality is very low, and if the weight is below three or four pounds 
and the length less than eighteen or nineteen inches, that the functions 
and organs are not developed sufficiently for use, and that unless unusual 
care is taken in the treatment of such cases, they will soon die. 

Treatment. — The treatment of a premature infant should be begun at 
once, as every minute of the exposure to which infants at term are usually 
with safety submitted is of the greatest danger to the premature infant, and 
greatly enhances the difficulty of saving its life. The bodily temperature, 
on which the vitality is dependent, is reduced very rapidly, and exposure 
to such conditions as are abnormal to those of intra-uterine life and to 



PREMATURE INFANTS. 265 

undeveloped organs is to be at once guarded against. The abnormal 
conditions to be avoided are light, sound, touch, cold and impure air. To 
accomplish this the following rules are indicated : 

I. There should be a receptacle which shall guard the infant from the 
deleterious influences of extra-uterine life. 

II. The receptacle should be such that it can be obtained quickly and 
transported rapidly, and therefore should be kept at some central and con- 
venient station. 

III. The place where the receptacle is kept should be free from the in- 
fluence of any disease. 

IV. The receptacle should be so constructed as to make it possible for 
it to be absolutely cleansed and disinfected each time after it has been used, 
hence it should be made of metal. 

V. The receptacle should, as soon as the infant is placed in it, be 
under the observation of trained nurses night and day. 

VI. The food for the infant should be regulated with the greatest pre- 
cision, with the closest attention to minute details, and if possible, at a 
milk-laboratory. 

VII. The premature infant should not be bathed, but should be rapidly 
covered with warm, fresh sweet oil, and wrapped up in absorbent cot- 
ton, only the face being left exposed. The cotton around the buttocks 
should be separate from that around the body, head, and upper extremi- 
ties, so that it can be changed oftener, as after the discharge of urine and 
faeces. The remaining cotton need not be changed oftener than once in 
forty-eight hours, and at each change of cotton the oil can be reapplied. 

It will be found that the cotton is remarkably cleansing, and will ob- 
viate entirely the necessity for using water. The cotton and oil should be 
thoroughly warmed before being used. The infant should not be re- 
moved from its receptacle when these changes are being made or when it 
is fed. The surroundings and receptacle should be adapted to the indica- 
tions just stated. All the possible causes which may reduce the vitality 
must be thoroughly understood and obviated, and it must be appreciated 
that a failure to recognize and obviate any one of these causes may defeat 
the benefit which should arise from attending to all the others. The 
premature infant, therefore, should, so far as possible, be restored to the 
condition that it has been forced out of, — namely, a condition of darkness, 
silence, warmth, and a medium free from physical shock and pathogenic 
micro-organisms. 

Weight. — It is important to remember that the weight of premature 
infants of the same age varies at birth, just as we have seen in the case 
of infants born at term. 

In treating these cases, observance of their weight is of the greatest 
importance, and until we have obtained a regular progressive daily in- 
crease in their weight we are never sure that they are thriving sufficiently 
to live. The daily gain which the premature infant should make has not 



26Q PEDIATRICS. 

yet been determined, but it is much less than is expected when an infant 
is born at full term, and may be stated to be about 10 to 20 grammes (J 
to § ounce). Any decided loss in weight, such as 30 to 40 grammes (1 
to 1J ounces), beyond what would occur from natural causes, should 
make us look upon the infant as being in a critical condition and impress 
upon us the importance of taking active measures to prevent further loss. 
This loss in weight must, as it is relatively so small, be carefully adjusted 
to the loss which naturally occurs from the faecal discharges. Thus, the 
total amount of loss in weight from the faecal discharges may amount in 
these premature infants to from 30 to 60 grammes (1 to 2 ounces) for each 
faecal discharge, and this may entail a considerable loss of the infant's 
weight in the twenty-four hours beyond that occasioned by defective 
nutrition. 

The knowledge of the daily weight of a premature infant is the prin- 
cipal index of the changes in its vitality which occur very rapidly, and it 
is by the weight that we are guided in our daily adaptation of the food to 
the infant's condition, and are also informed as to whether greater or less 
warmth, more oxygen, or stimulants are indicated. 

The handling, however, which is usually necessary to obtain the 
weight is dangerous, as it reduces the vitality. This danger should be 
obviated by having the receptacle balanced on correct and sensitive 
scales. The premature infant's life is so difficult to preserve that we 
should make use of every device which our ingenuity can suggest and 
which is within the limits of possibility of the especial case which we are 
called upon to treat. The receptacle for the immediate occupation of the 
newly born premature infant therefore becomes a very important part 
of the treatment. 

Receptacle. — In the treatment of premature infants only one of the 
principal methods of maintaining their viability usually receives much at- 
tention. It is commonly supposed that if the atmosphere which sur- 
rounds the infant is kept at a sufficiently high temperature all that is 
requisite has been done for its safety. This is sometimes accomplished 
by placing the infant in a room where the temperature is as high as the 
nurse in charge of it is able to endure. This procedure is necessarily a 
very uncomfortable one for the nurse, and at times renders it almost im- 
possible for her to use her mind intelligently. It also requires a much 
more frequent change of nurses than would be the case if the atmosphere 
of the room were cooler. Another means of preventing undue loss of 
heat is to wrap the infant in cotton-wool and place it in a basket lined 
with hot-water bottles. 

Incubator. — If possible, the infant should be placed in an apparatus 
which is called an incubator. These incubators have been used for many 
years in different parts of the world, notably in Paris. They are of dif- 
ferent forms, some better adapted than others for carrying out the differ- 
ent factors of the problem. Some of them are made of tin, with double 



PREMATURE INFANTS. 



267 



walls, so that hot water can be continually kept in them, and thus suffi- 
cient warmth be applied to the infant. Others are made of wood, and 
kept warm by means of hot- water bottles introduced into them from below. 

The name incubator has been applied to these various devices for 
keeping up the animal heat of the infant. It is a misnomer, for incuba- 
tion means hatching, and in the precise sense of the word, the premature 
infant is already hatched and has been incubated. What we accomplish 
by this apparatus is analogous to what is done to keep up the animal 
heat and preserve the lives of young chickens after they are hatched, and 
the name brooder would be more applicable to machines devised for pre- 
serving the lives of premature infants than the term incubator. The word 
incubator is, however, so generally used to represent an apparatus in- 
tended to preserve the premature infant's life until it has attained the age 
of two hundred and eighty days, that it will, in all probability, for the 
present be retained. 

When it is impossible to obtain an incubator at once for preserving 
the premature infant's animal heat, it can be treated in the way already 
referred to, by placing it in a room in which the temperature has been 
raised as high as can be comfortably borne by the nurses, and in a basket 
heated by hot- water bottles. Such a case is represented in Fig. 65. 

Fig. 65. 




Infant premature at twenty-eighth week. Birth-weight, 1200 grammes. Age, 11 weeks. Treated 
in basket heated by hot-water bottles. Temperature of air in basket shown by thermometer introduced 
between the side of the basket and the blanket. 



Fig. 66 represents an incubator devised by me with the aid and coun- 
sel of Mr. G. E. Gordon and Mr. J. P. Putnam. It is intended to cover 
the requirements needed to preserve the lives of premature infants. It 
should be made as large as possible. It is, however, so expensive that 
incubators of wood, though objectionable for many reasons, especially 
that of infection, will be more commonly used. It is always, however, 
my wish, if possible, to use what is best, no matter what the cost, where 
such an important and difficult problem as the saving of a premature 
infant's life is to be solved. The expense of such an incubator as this 
one, while too great for any one individual, is comparatively insignificant 



268 



PEDIATRICS. 




Incubator for premature infants. A, scales for weighing 
infant ; B, glass lid of incubator ; C, fresh-air box, contain 
ing clock-work and fan ; D, lamp for heating water-jacket . 
E, chimney ; F, return flue from heating flues ; G, return 
fresh-air flue ; H, entrance for fresh air ; I, connection for 
oxygen tank ; J, mixing valve ; K, ventilating exit ; L 
anemometer. 



for a number. The incubator at present must necessarily be an expensive 
machine, but if provision should be made for it in combination with such 

scientific facilities for infant 
Fi Q - 66 - feeding as already recom- 

mended, I believe that any 
community would find it of 
infinite benefit. I am also 
sure that there would result 
saving of life for the people, 
and saving of time and ex- 
pense for the physicians, com- 
bined with the greatest satis- 
faction to both people and 
physicians. Such a combina- 
tion — in cities of a milk-labora- 
tory, or in the country of a 
Babcock fat-tester, with an in- 
cubator, kept in one central 
station — I hope to see estab- 
lished everywhere. One such 
station for districts which might 
be included in a radius of ten 
or even of twenty miles would be amply sufficient to accomplish very 
favorable results. 

The incubator (Fig. 66) is intended to fulfil the conditions of a house 
for the premature infant, and it practically meets the indications called for 
on page 265. After being used, it can be completely disinfected and 
cleansed. For purposes of disinfection, and that it may not absorb micro- 
organisms or dirt of any kind, which in wooden receptacles invariably 
cause a decided odor, it is made entirely of metal. 

It is supported on three wheels, preferably made of light steel, two 
behind and one guiding wheel in front. A handle is used to push it to 
different parts of the room, or, if necessary, to an adjoining room, so that 
the mother can see her infant if she is too sick to leave her bed. The top 
of the incubator is about 91 cm. (3 feet) from the floor, so that the nurse 
does not have to stoop unnecessarily, but at the same time can, when sit- 
ting down, see into it from above. The body is made of copper ; the 
walls are double, and insulated on the outside, to prevent radiation. The 
water used for heating circulates on all sides, and the infant is thus warmed 
by direct radiation. The top of the incubator is covered in the middle 
by a thick plate-glass lid, which can be raised sufficiently to allow the 
hands and arms of the nurse to be freely used, and is by a simple con- 
trivance kept from falling down while the infant is being fed or cleansed. 
A chain prevents the lid from falling backward. On the under side of the 
glass lid is a fine wire sliding screen, which comes directly over the infant's 



PREMATURE INFANTS. 269 

head and between it and the glass. This is simply a precaution against 
the possible breakage of the glass lid and consequent injury to the infant. 

The plated box (C) attached to the upper front end of the incubator 
contains some strong clock-work with a fan attachment. The oval open- 
ing in the clock-box admits the air to the incubator. Below the opening 
for the fresh air is a window, through which the fan and clock-work can 
be watched. 

Just below the air-opening and above the clock-work is a fine open wire 
shelf, on which is spread a thin layer of cotton- wool. The air, which by 
means of the fan is drawn into the box, is sifted through the cotton and 
carried down the air-shaft (H) directly into the incubator. In this air- 
shaft (H) there is a small stop-cock (7). This is the point of attachment 
for the tube from the oxygen tank, to be used when oxygen is needed to be 
mixed with the entering air-supply. The admixture of oxygen with the 
air in the incubator I have found of great value when the infant is losing 
in weight. 

In this air-shaft, also, is attached a valve, which is so regulated by a 
register handle that the air can be utilized either above or below the boiler, 
according as it is needed. 

The bottom of the incubator constitutes an air-chamber, and in this is 
a boiler which, with its heating or combustion direct and return flues, 
warms the interior of the apparatus. 

Above the boiler is placed the platform of a scales. To have the in- 
fant's bed continuously on a scales is of very great importance, as while 
seeing from hour to hour the variations in weight the danger of handling 
the infant to weigh it is obviated, and it need never be removed from the 
incubator. The balance power of the scales is on the top of the back 
end of the incubator. The platform of the scales acts as the support for 
a metal pan on which the infant is placed. This pan should be made of 
sheet iron, enamelled on both sides with white porcelain enamel, and 
should have handles at either end to facilitate its removal from the incu- 
bator. From the ends of this pan is hung by wires, which can be easily 
attached or detached, a light frame made of four steel rods crossed. On 
this frame is tied with tapes a piece of strong cotton cloth. This cloth is 
the bed, on which the infant is placed wrapped in clean absorbent cotton. 
This cotton cloth is about 2.5 cm. (1 inch) above the bottom of the pan. 
The infant's head is turned to the back end of the incubator. 

At the front end, opposite the foot of the infant's bed, is the exit (6r) 
for the vitiated air. This exit passes through the end of the incubator and 
enters a ventilating pipe which has at its top an anemometer (L). The 
bottom of the shaft is outside the incubator, and has a closed cone-shaped 
end, which is enclosed in a metal box in such a way that a lamp (D) can 
be placed under it. The heat from this lamp answers two purposes ; one 
of which is, by keeping the ventilating shaft hot, to aid the ventilation, and 
the other is to heat the water in .the boiler. A register-valve (J) attached 



270 



PEDIATRICS. 



to the pipe can shut off the heat if necessary from the boiler, and allow it 
to go directly up the double pipe {E, K), whereby its entire power will be 
used in promoting ventilation, or the valve may be set so as to direct the 
flame partially into the boiler, thus placing its temperature completely 
under control. In this way the heat from the lamp (which is enclosed 
in the box) is without danger entirely utilized for heating and ventilation. 

Fig. 67 shows a section of the incubator. 

The smoke-flue of the lamp, marked " Heating Flue," passes through 
the centre of the boiler, marked " Water" in the diagram, as far as to the 

Fig. 67. 



GLASS PLATE £ //v. TH/CK 




Section of incubator. I, lid of fresh-air box, open; A, entrance of fresh air; C, cotton, resting on 
wire shelf above clock-work ; F, clock-work and fan ; S, valve regulating hot and cold fresh air ; 0, 
pipe for oxygen attachment; C. F., cleaning flue; Door, door to lamp-box; W, wire frame to protect 
against breakage of lid. 

cleaning-flue, marked C. F. Thence it returns and enters the upright 
pipe, marked "Heating Flue Exit." The horizontal return-flue is not 
shown in the figure, because it is behind the horizontal arm. The little 
gate- valve shown directly above the lamp regulates absolutely the amount 
of heat which is allowed to pass through the boiler, and the temperature 
of the warm water therein may be tested by a thermometer, inserted at 
any opening which may be provided for it as directed when the incubator 
is built. 

The fresh-air flues are constructed as shown, one above and one below 
the boiler. One flue comes in contact with the upper or hottest part of 
the boiler, and presents a very large surface of contact by being flattened 
so as to cover completely the upper side of the boiler. The other flue 
touches the bottom of the boiler only in one line, or not at all, so that 
the air passing through it is practically unaffected by the boiler heat. By 
this arrangement the temperature of the fresh air can be regulated at will 
by the attendant by simply raising or lowering the valve S. 



PREMATURE INFANTS. 271 

In virtue of the large amount of heating surface of the heating flue in 
this apparatus, it is found that a very small flame suffices to keep up the 
desired temperature, and it results from this that no injurious products of 
combustion contaminate the air of the room. A very small alcohol lamp 
can be used, while with a less scientific arrangement this fuel might be 
found too expensive. 

It is probable that an electric current will be found most suitable to 
supply the heat in place of the lamp, as well as to drive the fan, and this 
can be very easily accomplished with a small battery. 

By packing the water-jacket with asbestos, external radiation is pre- 
vented. 

The heating of the incubator varies as to time and degree according to 
the atmosphere of the room where it has been standing. If, however, the 
temperature of the room is 21.1° C. (70° F.), and the temperature of the 
water which is introduced into the boiler is about 40.5° C. (105° F.), it 
will be found that after the cool air in the incubator has been displaced the 
temperature of the air in the incubator will in about fifteen minutes rise 
to 35° C. (95° F.). The temperature will remain at this point for about 
half an hour. As soon as the temperature begins to fall the alcohol lamp 
should be lighted, and as soon as the temperature of the water in the 
boiler rises above 35° C. (95° F.) the lamp should be extinguished. By 
careful regulation of the lamp and of the fresh air by means of the 
register-valves, an intelligent nurse can keep the temperature of the 
incubator at whatever degree the physician orders. The thermometer 
should, in order to show accurately the temperature of the air which the 
infant is breathing, be beside it on its bed, as when attached to the lid it is 
influenced by changes of temperature in the room. 

If any difficulty arises from the temperature not responding quickly 
enough to the register- valves and lamp, it is well to draw off a little hot 
water and replace it by some cold water if it is desired to lower the tem- 
perature, while to raise the temperature the withdrawn water is to be 
replaced by hot water. In practice it has been found that this latter 
method of regulating the temperature is more satisfactory than by the 
lamp. If the incubator is not kept in one place, as a hospital, but has to 
be transported, it would be well to lighten it as much as possible by 
removing the wheels and making it of some metal lighter than copper, as 
it is very heavy. 

Nurses. — The incubator is not intended to obviate the necessity of 
skilled nursing. On the contrary, a nurse should be in constant attend- 
ance night and day. She should have all the details of the infant's care 
and the mechanism of the incubator explained to her minutely, for an 
emergency may arise at any time, and always requires to be dealt with 
immediately. 

The incubator supplies the means for exact treatment, but intelligent 
minds and trained gentle hands are indispensable. The nurse should fre- 



272 



PEDIATRICS. 



Fig. 



quently observe the infant through the glass lid, and should be certain 
that the anemometer is in constant motion. 

Apparatus Connected with the Incubator. — A stethoscope with rubber 
arms and small cup is the best adapted for examining the infant in the 
incubator, as it can be bent in any direction, and is suited to the infant's 
size. 

A piece of dark cloth should be kept over the glass lid, to exclude the 
light, while the sun should be allowed to shine freely into the room. The 
air in the room should be frequently changed and kept as pure as possible. 
The room should be absolutely free from dust and should only contain 
some polished wood chairs and tables. The floor should be bare, and, if 
possible, of polished hard wood. 

The method of feeding the infant in the incubator is important. It fre- 
quently happens that the premature infant is too weak not only to suck the 
breast, but also to be fed from the bottle. In such 
cases it is customary to use a spoon or a medicine- 
dropper. These, however, are very unsatisfactory in- 
struments. The food is liable to be spilled, the spoon 
or dropper has to be frequently filled, and much time 
is taken to complete the feeding. The lid of the incu- 
bator, also, should not be kept open for a longer time 
than is unavoidable. I have lately made use of a de- 
vice suggested by Dr. Breck. It is simply a glass cylin- 
der (Fig. 68), 12 cm. (4f inches) long and 2.4 cm. (1 
inch) in diameter. The cylinder is graduated to 2 c.c. 
(J drachm), and holds 36 c.c. (9 drachms). It is shaped 
at one end so as to have a small rubber nipple fitted to 
it. The large end is covered by a rubber cot. The 
rubber cot, which has no holes, acts as an air-reservoir, 
and by simply introducing the small perforated nipple 
into the mouth and gently pressing the rubber cot the 
food is slowly forced down the infant's throat, without 
choking it and without obliging it to suck or apparently 
to use any effort. To fill the tube the rubber nipple 
and cot are removed, and the required amount of food 
is poured in at the large end, while the small end of the 
cylinder is plugged with a rubber stopper shown in the 
figure beside the feeder. 

This method of feeding is especially desirable for a 
weak premature infant in an incubator, because it entails 
no loss of strength on the part of the infant, and can be 
easily managed by the right hand of the nurse, while her 
left hand supports the infant's head. This method is far preferable to that 
of gavage, which is not so easily managed by the nurse and is more 
exhausting to the infant. 



i/ 



Feeder for premature 
infants (reduced one- 
half). 



PREMATURE INFANTS. 273 

Food. — The feeding of premature infants should be as exact as pos- 
sible. If the infant is vigorous enough to suck, and if the breast-milk 
is of proper quality, that is not too strong, the infant can be put to 
the breast every one and one-half hours. We must consider, how- 
ever, certain disadvantages of nursing premature infants which do not 
arise in the nursing of infants at term. Frequent nursing, such as every 
hour, which is so often required with premature infants, tends to disturb 
the quality of the breast-milk and to increase the solids. This is often 
disastrous to the infant, as the least overtaxing of its digestion may prove 
fatal. Then, again, the premature infant can often digest only much lower 
percentages of fat, sugar, and proteids than are found in normal breast- 
milk, so that a normal milk may prove fatal by being too strong. If two 
or even three wet-nurses can be obtained, the intervals of nursing each 
one of them can be made every three hours, and thus while the solids in 
their milk will be lessened, the infant .can be fed every hour. This method 
of feeding if possible is desirable. The laboratory method of feeding with 
exact and low percentages gradually increased is the most rational and 
practical, especially if the infant is too weak to nurse at the breast. 

Amount. — The amount of food to be given at each feeding is very 
important. By referring to the weights and gastric capacities of the pre- 
mature infants already described (Figs. 60, 61, 62, page 260) it will be 
seen how misleading is the weight of the infant if we take it as an exact 
index of the gastric capacity. We must, however, take the weight into 
account, as, from even the imperfect data at our command, the weight 
of premature infants appears to bear a decided relation to their gastric 
capacity. We should at least be more inclined to increase rapidly the 
initial amount of food given in the case of an infant of large weight than 
in that of a small one. It is better to begin with too small rather than 
too large a quantity. By watching carefully for signs of hunger, a desire 
which the infant expresses by feeble but continuous cries, which stop 
Avhen the food is given to it, we can gradually increase the amount until 
it seems to want it at regular intervals, is satisfied, and sleeps quietly 
during the intervals of feeding. 

By referring to the foetal stomachs represented in Figs. 60, 61, 62, 63, 
pages 260, 261, it will be understood that it is safer to begin with 4 or 
5 c.c. (about 1 drachm) and gradually to increase the amount up to a point 
where our very imperfect knowledge on this subject, derived partly from 
the weight of the infant, makes us believe that the stomach is full, than to 
begin at once with the larger amount. It is absolutely necessary that we 
should avoid undue distention of the stomach, as this may prove fatal. 

Intervals. — The premature infant's stomach is small, and is, in all 
probability, emptied quickly, and, as food is necessary for keeping up the 
animal heat required for the maintenance of its life, the intervals of feed- 
ing should be much shorter than those required for the infant at term. In 
the early days, and in fact weeks, of life I have found that it is better to 

18 



274 PEDIATRICS. 

feed the premature infant regularly every hour. Four or five weeks after 
birth, if it is gaining in weight and is digesting well, these intervals can be 
lengthened, and by the time it arrives at term we can usually make the 
feeding intervals one and a quarter to one and a half hours, and a few 
weeks later two hours. 

Percentages. — The careful adjustment of the premature infant's food 
to its digestive organs is of even greater importance than in the case of an 
infant at term. There is no doubt that if we consider the hypersensitive 
condition and the undeveloped state of the digestive organs prior to birth, 
the most exact adjustment of the food to these digestive organs is abso- 
lutely necessary when a wet-nurse cannot be obtained. This adjustment 
is best accomplished by means of carefully prepared prescriptions at the 
milk-laboratory. Through this instrument of precision three important 
advantages are gained : (1) we insure a clean food free from micro-organ- 
isms ; (2) we can obtain low and properly balanced percentages of the 
constituents of the milk ; (3) we have, at any time, the power of exactly 
varying, to within a fraction of one-half of one per cent., the percentages 
of the three most important elements of the milk, — namely, the fat, the 
sugar, and the proteids. In addition to these latter two advantages pos- 
sessed by the substitute over the maternal method of feeding are others 
of almost equal importance. One advantage is the absence of variation 
in the substitute food arising from emotional causes, and another is that 
the infant need not be taken from the incubator to be fed. 

The following prescription is the one which I should begin with in feed- 
ing an infant premature at the twenty-eighth week : 

Prescription 42. 

R Fat 1.00 

Sugar 3.00 

Proteids : whey proteids, 0.25 ; caseinogen, 0.25 0.50 

24 meals, each 4 c.c. (1 drachm). 
Heat to 68.3° C. (155° F.). 
Eeaction faintly alkaline. 

If the infant is over twenty-nine weeks, or if it is unusually large for 
its age, and especially if it is unsatisfied, it is well in a few days to change 
the prescription to the following : 

Prescription 43. 

R Fat 1.50 

Sugar 4.00 

Proteids : whey proteids, 0.25 ; caseinogen, 0.25 0.50 

24 meals, each 8 c.c. (2 drachms). 

If the infant is over thirty-two weeks, the prescription should be 
changed in a few days, under the same conditions as in Prescription 42, 
to 



PREMATURE INFANTS. 275 

Prescription 44. 

R Fat 1. 50 

Sugar 5.00 

Proteids : whey proteids, 0.50 ; caseinogen, 0.25 0.75 

24 meals, each 12 c.c. (3 drachms). 

If the infant is over thirty-six weeks, the milk should, after forty-eight 
hours, be changed to 

Prescription 45. 

R Fat 2.00 

Sugar 5. 50 

Proteids : whey proteids, 0.75 ; caseinogen, 0.25 1.00 

24 meals, each 16 c.c. (4 drachms). 

The infant, however, under all circumstances, must be watched criti- 
cally, and any or all of the percentages of the elements or amounts of 
the food increased or decreased according to the individual indications. 

When the infant is born at the thirty-eighth or thirty-ninth week its 
development is usually so near that of the infant at term that the incubator 
will not be needed, and the food can be given in about the proportions 
which would be adapted to the early days of the infant at term (Prescrip- 
tion 16, page 215). 

Prognosis. — The prognosis in a premature infant during the early 
weeks of its life and until it is steadily gaining in weight must be guarded, 
as the mortality rate is very high, and these infants are apt to die suddenly 
simply from a lack of vitality. The younger the infant the greater is the 
danger of its dying. The most frequent causes of death among prema- 
ture infants are a lack of development of the thorax or lungs, atelectasis, 
an insufficient supply of fresh air, improperly cleansed incubators, leading 
to various forms of infection, undue exposure, careless handling, and im- 
proper feeding. Hutinel, from his experience with premature infants at 
the Hospice des Enfants-Assistes, attributes the high mortality to the fol- 
lowing causes : 

(1) Some infants are not viable; their organs being incompletely 
formed, cannot perform the functions necessary for the maintenance of 
life. 

(2) Others present malformations inconsistent with life, or are affected 
with an hereditary taint, such as syphilis, which has already done irrep- 
arable damage at the time of birth. In these two cases the incubator is 
useless ; if it protects against cold, which is all it can do, it cannot perfect 
undeveloped organs or cure hereditary blemishes. 

(3) Some babies which seem well at birth fall ill soon after they are 
put into an incubator, and die there. In these cases the incubator is not 
to blame. 

(4) This class includes premature infants who are apparently well 
developed and comparatively healthy when placed in the incubator. It 
seems as if they ought to develop, but they die after a few days. The 



276 PEDIATRICS. 

author considers that they die from various infections. These are not 
simple surface infections, for the actual presence of the pus-producing 
organisms in the blood have been frequently demonstrated. The .infec- 
tions are due to the lack of resisting power on the part of the infantile 
mucous membrane which cannot oppose the entrance of germs if the 
surrounding atmosphere is contaminated. That the air comes from out- 
side is not sufficient to eliminate contagion, as the incubator must be 
opened from time to time, and the patients are attended by those who 
may readily infect them. The author insists most strongly upon a well- 
ventilated and sunny room for incubators, and holds that in hospitals 
there should be at least three apartments devoted to the rearing of pre- 
mature infants : one for the healthy, one for the ailing, and one for the 
ill ones. Germs undoubtedly flourish in an incubator with its constantly 
elevated temperature, so that an infant should be removed just as soon 
as it is able to maintain its temperature at 98.4° F. for thirty-six or forty- 
eight hours. It should then be enveloped in cotton and surrounded with 
hot bottles. Plenty of fresh air and sunshine are required. If one of these 
babies falls ill it must be separated at once from the others. In regard to 
putting it back into the incubator, infection when it occurs is more likely 
to begin outside. Incubators should be so constructed that they can be 
readily cleansed. The temperature changes involved in doing this are of 
little importance provided they are not too prolonged. By following these 
principles the author has lost only three out of twenty-one cases, aver- 
aging less than four and a half pounds. 

The following record and chart are those of a premature infant who 
was kept in a room with a temperature of 23.8° C. (75° F.) and in a 
basket heated to 29.4° C. (85° F.). 

TABLE 59. 

Weight for Sixty-one Days of Infant Premature at Thirty-two Weeks. 
Day of Life. Grammes. (Pounds. Oz.) Remarks. 

Birth-weight 2964 (6 8) Cow's milk, with spoon. 

Third. 2724 ( 6 0) Mother's milk, with spoon. 

Sixth 2814 (6 3 ) Mother's milk, with spoon. 

Ninth 2964 (6 8) Mother's milk direct from breast. 

Thirteenth 3178 (7 0) Mother's milk direct from breast. 

Sixteenth 3388 (7 7 ) Modified milk. 

Twentieth 3598 ( 7 14) Modified milk. 

Twenty-third 3812 (8 6) Modified milk. 

Twenty-seventh 4116 ( 9 1) Modified milk. 

Thirtieth 4236 (9 5) Modified milk. 

Thirty-third 4476 (9 13) Modified milk. 

Thirty-seventh 4600 (10 2) Modified milk. 

Forty-first 4840 (10 10) Modified milk. 

Forty-fourth 4900 (10 12) Modified milk. 

Forty-eighth 4994 (11 0) Modified milk. 

Fifty-first 5084 (11 3) Modified milk. 

Fifty-fifth 5234 (11 8) Modified milk. 

Fifty-eighth 5324 (11 11) Modified milk. 

Sixty-first 5384 (11 13) Modified milk. 



PREMATURE INFANTS. 



277 



CHAET 3. 





Days of Life 




F 

107° 
106° 
105° 

104° 
103° 
102° 
101° 
(00° 
99° 

9a6 c 

97° 
96° 
95° 

I BO 
150 
140 

(30 
120 

no 

100 
90 
80 
70 


i 


2 


3 


4 


5 


6 


7 


8 


9 


10 


n 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 


c 

♦ 16" 
*I (° 

40.5° 
40.0° 
39.4° 
38.8° 
38.3° 
J7.7? 
37.2° 

vs 

35.5° 
35-Of 

<b 

-5! 








-M K 


M g 


M L 


M b. 


M K 








M £ 




M K 


M B 


at E 


M T. 


M X 


HI 


M E 


M E 




























































































































































































































j 
















- 




















/ 


r^ 


/ 




L 


\ 














/ 


i/ 














/ 


\j 










\ 


y 


^ 


/ 


s 


,> 


r ' 


k/ 






\f 


/ 


7 
























V. 














v.. 




fed 


^ 


s 
















































































































































































































































A 
















y 


V 


\ 


h 


/ 








A 








A 


'\ 


/ 


V 


1 














\ 


h 


/ 








1 \ 


/ 


• 


v 










V 




1/ 


^N 



















































































































































































































The question is often asked whether premature infants, even if their 
lives are saved, can eventually be as well developed physically and men- 
tally as are those born at term. In my experience there seems to be no 
question that when once we have succeeded in making the infant gain 
steadily in weight and assume the appearance of an infant at term its 
subsequent condition differs in no respect from that of infants born at 
term. Fig. 69 illustrates the wisdom of doing all in our power to save the 
lives of these infants, as it represents at nine months what was one of 
the worst cases of lowered vitality and extreme emaciation in a premature 
infant that I have ever seen. 



This picture was taken when the infant was nine months old and weighed 8400 
grammes (17^ pounds). As its birth-weight was 2040 grammes (about 4^ pounds), 
it will be seen that its weight has quadrupled. He was fed entirely on modified milk 
from the laboratory during the first year, and was a fine large boy, walking and talk- 
ing at two years of age. He was perfectly healthy and well developed both physi- 
cally and mentally. 

His sister, who was premature at the twenty-eighth week, was eight years old. 
She was well developed and strong, and was unusually bright and intelligent for her 
age. She was, in fact, decidedly in advance mentally of the other children of her age 
at school. 

The following is the record of an infant prematurely born at about the 
thirtieth week, and weighing 2850 grammes (about 5 pounds 15 ounces), 
which was the first premature infant that happened to be treated in the 
incubator represented in Fig. 66, page 268. It illustrates the value of 
careful and exact incubation and feeding. 



278 



PEDIATRICS. 



The infant was born at ten minutes past three in the morning of February 16, 
It was placed in the incubator at 9 p.m. of the same day, the temperature of the incu 
bator being 34.4° C. (94° F.). 

Fig. 69. 




Infant premature at 30 weeks. Birth- weight, 2040 grammes (4% pounds. ) Treated in incubator 64 days. 
Age, 9 months ; weight, 8400 grammes (17% pounds.) 

On the following day, February 17, the infant was given by the nurse 4 c.c. (1 
drachm) of diluted cow's milk every hour for three feedings, which he vomited almost 
immediately after taking. The intervals of feeding were then increased to two hours, 
but the milk was not retained. The nurse then gave him 2 c.c. (J drachm) every three 
hours during the night, which he retained for a number of feedings, but then vomited 
bile and mucus, together with the undigested food which had been given him. 

February 18 the infant was found to have lost 420 grammes (14 ounces) in weight, 
to be very weak, and to be unable to retain the milk diluted with water. The me- 
conium came away on this day, and there was a uric acid stain on the napkins. The 
infant was very restless. Its respirations were irregular, and its feet and hands were 
cold. The temperature of the incubator, which up to this time had been kept at 34.4° 
C. (94° F.), was lowered to 33.8° C. (93° F.), as the infant had begun to perspire. A 
substitute food was ordered from the milk-laboratory on this day, the prescription for 

which was as follows : 

Prescription 46. 

R Fat 1.00 

Sugar 3.00 

Proteids . 0.50 

To be heated for thirty minutes at 75° C. (167° F. ). 

Lime-water 5.00 

24 tubes, each containing 4 c.c (1 drachm). 



PREMATURE INFANTS. 279 

This food was given to the infant every hour. 

On the following day, the 19th, the record was that the food had been retained, that 
the infant had seemed so hungry that the amount had to be increased to 10 c.c. (2 \ 
drachms), and that it was found advisable to feed it every two hours rather than every 
hour. There was no vomiting. There were two movements of the bowels, which 
still showed evidences of undigested milk and some meconium. The infant's weight 
on this day was found to be the same as on the previous day, 2300 grammes (5 pounds 
1 ounce). 

On the following day, February 20, the infant was found to have gained 30 
grammes (1 ounce). It was taking its food regularly every two hours, alternating with 
the mother's milk, which had come in considerable quantity. There were still evi- 
dences of uric acid in the urine. The temperature of the incubator was kept at 31.6° 
C. (89° F.). 

On the following day, February 21, the weight was as on the previous day. 2230 
grammes (5 pounds 2 ounces). The color of the faecal discharges was yellowish 
brown. There was only one discharge in the twenty-four hours, obtained by the use 
of a suppository. The temperature of the incubator was kept at 30° C. (86° F.). 

On the following day, February 22, it was found that the infant had lost 60 
grammes (2 ounces). The substitute food was then given every two hours, alternating 
with the breast-milk. On that day there were three yellow well-digested movements. 
The temperature of the incubator was kept at 29.4° C. (85° F.). The infant seemed 
stronger, was very quiet, and slept except when it awoke to receive its food. 

On the following day, February 23, there is no record of the infant's weight, but it 
was evidently in a very precarious condition and seemed exhausted. It did not take 
its nourishment readily. It had five small faecal discharges in the twenty-four hours, 
which, however, were yellow and fairly digested. 

On the following day, February 24, the breast-milk was omitted, and 4 c.c. (1 
drachm) of modified milk were given every two hours, the percentage of the sugar 
being raised from 3 to 3.5. There were four small faecal movements during the day ; 
the first one was green, the last three were yellow and decidedly better digested. The 
temperature of the incubator was kept at 29.4° C. (85° F.). During the day the 
infant gained 60 grammes (2 ounces) in weight. It was so weak on these two days 
that it would have been dangerous to take it out of the incubator to weigh it, so that 
the continual record of the weight which could be obtained by the scale-bed of the 
incubator was of the utmost value in regulating the changes in the food necessary to 
save the infant's life. 

On the following day, February 25, the infant's weight was found to be 2260 
grammes (5 pounds 3 ounces), an increase of 30 grammes (1 ounce). The percentages 
in the modified milk were then changed to the following : 

Prescription 47. 

R Pat 1.50 

Sugar •. 4.00 

Proteids 0. 75 

One drop of brandy was given with each feeding. There was one faecal discharge, 
which was yellow and well digested. On this day 4 c.c. (1 drachm) of food were given 
to the infant every two hours until its feeding at 10.30 p.m. After this it seemed 
so hungry that at midnight 36 c.c. (9 drachms) were given, at 3 a.m. 40 c.c. (10 
drachms) were given, and at 5.30 a.m. 30 grammes (1 ounce) were given. The weight 
was now found to be 2420 grammes (5 pounds 5 ounces), an increase of 60 grammes 
(2 ounces) in the twenty-four hours. The amount of food which the infant had 
taken in the previous twenty-four hours was found to have been 375 grammes (12£ 
ounces). The faecal discharges were yellow and well digested. Rrandy was continued. 



280 PEDIATRICS. 

The temperature of the incubator was kept at 29.4° C. (85° F.). At times a little 
breast-milk was given to the infant, in order to satisfy the mother, but it evidently 
did not agree with it. 

On February 27 the weight was found to be 2450 grammes (5 pounds 6 ounces). 
The prescription for the modified milk was then changed as follows : 

Prescription 48. 

R Fat 2.00 

Sugar 5.00 

Proteids 0.75 

Thirty grammes (1 ounce) of this were given to the infant every two hours during 
the day, and every two and one-half hours during the night. One yellow well-digested 
faecal discharge was obtained by means of a suppository. The temperature of the in- 
cubator was then reduced to 27.7° C. (82° F.). 

The following day, February 28, the weight was found to be 2480 grammes (5 
pounds 7 ounces). The brandy was still continued, and there was one yellow well- 
digested faecal discharge. The breast-milk had been entirely omitted, and 450 grammes 
(15 ounces) of modified milk had been taken in the twenty-four hours. 

On the following day, March 1, it weighed 2510 grammes (5 pounds 8 ounces). 
The amount of modified milk given was 495 grammes (16J ounces) in the twenty-four 
hours, and one drop of brandy was given with each feeding. There was great im- 
provement in the infant's appearance, and it was much stronger. 

On the following day, March 2, there had been no increase or loss in weight. The 
temperature of the incubator was kept at 27.2° C. (81° F.). 510 grammes (17 ounces) 
of the modified milk were taken in the twenty-four hours. There was one faecal 
movement, well digested and yellow. 

On the following day, March 3, the weight was found to have increased to 2600 
grammes (5 pounds 11 ounces). The percentages of the modified milk were then 
changed to the following : 

Prescription 49. 

R Fat 2.50 

Sugar 5.00 

Proteids 1.00 

There were two well-digested faecal discharges on this day. The temperature of 
the incubator was reduced to 25° C. (77° F.). 615 grammes (20J ounces) of the modi- 
fied milk were given in the twenty-four hours. 

The following day, March 4, the infant was found to have lost 60 grammes (2 
ounces), and the temperature of the incubator was therefore raised to 26.6° C. (80° 
F.). 630 grammes (21 ounces) of modified milk were taken in the twenty-four hours, 
and there was no especial change in the infant's condition. 

On the following day, March 5, 30 grammes (1 ounce) in weight were found to have 
been gained, and the infant was looking better and decidedly gaining in strength. It 
was evident that the proper temperature for this especial infant at this, age and at thi& 
period of its development was 26.6° C. (80° F.). 

After this time the infant continued to develop normally, and on being taken out 
of the incubator in April was thriving in every way. 

When five months old it weighed 7110 grammes (14 pounds and 13 ounces). 

The next case was that of an infant which was four weeks premature, and which 
was, for a premature infant, tolerably vigorous at birth. It was under the care of Dr. 
Samuel Breck, with whom I saw it in consultation. It was not placed in an incubator. 
Unfortunately, its nurse had no idea of the importance of protecting it from external 
influences. It was fed on a carefully prepared food from the milk-laboratory, and began 
to gain in weight, and in every way showed no evidence of its vitality being interfered 



TAJ 

Showing Details of Sixty-four Days of Life in 











Percentages of Food. 


F^cal Discharges. 








Days 


Intervals 

BETWEEN 


Amount 

AT EACH 












Weight 




OF 
















Life. 


Meals. 


Meal. 








Lime- 
Water. 






















Fat. 


Sugar. 


Proteids. 


No. 


Character. 


W'ght. 












C.c. 


Dr'rns. 














Oz. 


Grms. 


Lbs. 


OZ 


1 










3 per ct. 








meconium. 




2040 


4 


4 












sol. in 


























aq. dis. 


















2 


1 hour. 


4 


1 


1.00 


3.00 


1.00 


5.00 


2 


brown, small. 




2040 


4 


4 


3 


1 hour. 


4 


1 


1.00 


3.00 


1.00 


5.00 


2 


" 




2040 


4 


4 


4 


1 hour. 


4 


1 


1.00 


3.00 


1.00 


5.00 


2 


" 




2040 


4 


4 


5 


1 hour. 


4 


1 


1.00 


3.00 


1.00 


5.00 


2 


only fairly 
digested. 




2010 


4 


3 


6 


1 hour. 


4 


1 


1.00 


3.00 


1.00 


5.00 


2 


'* 




2040 


4 


4 


7 


1 hour. 


4 


1 


1.00 


3.00 


1.00 


5.00 


2 


<• 




2040 


4 


4 


8 


1 hour. 


4 


1 


1.00 


3.00 


1.00 


5.00 


2 


» 




2055 


4 


4) 


9 


1 hour. 


4 


1 


1.00 


4.00 


1.00 


5.00 


2 


yellow. 




2010 


4 


3 


10 


1 hour. 


4 


1 


1.00 


4.00 


1.00 


5.00 


2 


well digested. 




2025 


4 


3} 


11 


1 hour. 


8 


2 


1.00 


4.00 


1.00 


5.00 


2 


•' 




2025 


4 


3) 


12 


1 hour. 


8 


2 


1.00 


4.00 


1.00 


5.00 


2 


" 




2055 


4 


43 


13 


1 hour. 


8 ' 


2 


1.00 


4.00 


1.00 


5.00 


2 


" 




2070 


4 


5 


14 


1 hour. 


8-10 


2-2% 
2-2% 


1.00 


4.00 


1.00 


5.00 


2 


« 




2070 


4 


5 


15 


1 hour. 


8-10 


1.00 


4.00 


1.00 


5.00 


2 


« 




2070 


4 


5 


16 


1 hour. 


12 


3 


1.50 


5.00 


1.00 


5.00 


2 


" 


.... 


2160 


4 


8 


17 


1 hour. 


12 


3 


1.50 


5.00 


1.00 


5.00 


2 


■< 




2160 


4 


8 


18 


1 hour. 


12 


3 


1.50 


5.00 


1.00 


5.00 


2 


«« 




2100 


4 


6 


19 


1 hour. 


12 


3 


1.50 


5.00 


1.00 


5.00 


2 


«« 




2130 


4 


7 


20 


1 hour. 


12-14 


3-3% 


1.50 


5.00 


1.00 


5.00 


2 


«« 




2160 


4 


8 


21 


1 hour. 


16 


4 


1.50 


5.00 


1.00 


5.00 


2 


«« 




2175 


4 


8) 


22 


1 hour. 


16 


4 


1.50 


5.00 


1.00 


5.00 


2 


♦« 




2220 


4 


10 


23 


1 hour. 


16-18 


4-t% 


1.50 


5.00 


1.00 


5.00 


2 


«« 




2235 


4 


10J 


24 


1 hour. 


16-18 


4-4% 
4%-5 


1.50 


5.00 


1.00 


5.00 


2 


«• 




2250 


4 


11 


25 


1 hour. 


18-20 


2.00 


5.00 


1.00 


5.00 


1 


i< 




2280 


4 


12 


26 


1 hour. 


18-20 


4%-5 


2.00 


5.00 


1.00 


5.00 


2 


• s 




2280 


4 


12 


27 


1 hour. 


18-20 


4%-5 


2.00 


5.00 


1.00 


5.00 


1 


«« 




2295 


4 


12) 


28 


1 hour. 


18-20 


4%-5 


2.00 


5.00 


1.00 


5.00 


2 


« 




2310 


4 


13 


29 


1 hour. 


20 


5 


2.00 


5.00 


1.00 


5.00 


2 


" 




2310 


4 


13 


30 


1 hour. 


22 


5% 


2.00 


5.00 


1.00 


5.00 


3 


slightly green. 




2280 


4 


12 


31 


1 hour. 


22 


5% 


2.00 


5.00 


1.00 


5.00 


4 


" 




2287 


4 


12i 


32 


1 hour. 


22 


5% 


2.00 


5.00 


1.00 


5.00 


4 


" 




2295 


4 


12) 


33 


1 hour. 


24-26 


6-6% 


2.00 


5.00 


1.00 


5.00 


5 


" 




2295 


4 


12) 


34 


1 hour. 


28 


7 


2.00 


6.00 


1.00 


10.00 


8 






2295 


4 


12) 


35 


1% hrs. 


32 


8 


2.00 


6.00 


1.00 


10.00 


5 


yellow and 
well digested. 




2340 


4 


14 


36 


IM hrs. 


32 


8 


2.00 


6.00 


1.00 


5.00 


5 


" 




2400 ' 


' 5 " 





37 


\yi hrs. 
134 hr s- 
1% hrs. 


32 


8 


2.00 


6.00 


1.00 


5.00 


3 


" 




2460 


5 


2 


38 


48 


12 


2.00 


6.00 


1.00 


5.00 


3 


" 




2490 


5 


3 


39 


48 


12 


2.00 


6.00 


1.00 


5.00 


3 


ti 




2520 


5 


4 


40 


1% hrs. 


48 


12 


2.00 


6.00 


1.00 


5.00 


5 


•« 


' 3 ' 


2550 


5 


5 


41 


1% hrs. 


48 


12 


2.00 


6.00 


1.00 


5.00 


2 


" 


1 


2550 


5 


5 


42 


1% hrs. 
Itt hrs. 


48 


12 


2.00 


6.00 


1.00 


5.00 


2 


«« 


2550 


5 


5 


43 


48 


12 


2.00 


6.00 


1.00 


5.00 


1 


" 




2640 


5 


8 


44 


1% hrs. 


48 


12 


2.00 


6.00 


1.00 


5.00 


2 


" 


' 2% " 


2700 


5 


10 


45 


IK hrs. 
1% hrs. 
1*1 hrs. 


48 


12 


2.00 


6.00 


1.00 


5.00 


5 


" 


8 


2700 


5 


10 


46 


48 


12 


2.00 


6.00 


1.00 


5.00 


6 


«* 


9 


2640 


5 


8 


47 


48 


12 


2.00 


6.00 


1.00 


5.00 


6 


" 


9 


2640 


5 


8 


48 


1% hrs. 
1% hrs. 


48 


12 


2.00 


6.00 


1.00 


5.00 


4 


" 




2730 


5 


11 


49 


48 


12 


2.00 


6.00 


1.00 


5.00 


4 


" 




2790 


5 


13 


50 


1% hrs. 
IK hrs. 
154 hrs. 


56 


14 


2.00 


6.00 


1.00 


5.00 


6 


" 


' 6 ' 


2850 


5 


15 


51 


56 


14 


2.00 


6.00 


1.00 


5.00 


5 


«• 


7 


2850 


5 


15 


52 


64 


16 


2.00 


6.00 


1.00 


5.00 


6 


" 


&X 


2880 


6 





53 


\% hrs. 


64 


16 


2.00 


6.00 


1.00 


5.00 


5 


" 




2880 


6 





54 


1% hrs. 


64 


16 


2.00 


6.00 


1.00 


5.00 


2 


" 


' 3 ' 


2970 


6 


3 


55 


1% hrs. 


64 


16 


3.00 


7.00 


1.00 


5.00 


1 


44 


3 


2970 


6 


3 


56 


1% hrs. 


64 


16 


3.00 


7.00 


1.00 


5.00 


1 


" 


2 


3030 


6 


5 


57 


l%hrs. 
1% hrs. 


64 


16 


3.00 


7.00 


1.00 


5.00 


3 


" 


5 


3030 


6 


5 


58 


64 


16 


3.00 


7.00 


1.00 


5.00 


1 


" 




3090 


6 


7 


59 


1% hrs. 
1% hrs. 
1% hrs. 


64 


16 


3.00 


7.00 


1.00 


5.00 


3 


" 






312Q 


6 


8 


60 


64 


16 


3.00 


7.00 


1.00 


5.00 


1 


" 






3210 


6 


11 


61 


64 


16 


3.00 


7-00 


1.00 


5.00 


3 


" 






3150 


6 


9 


62 


1% hrs. 


64 


16 


3.00 


7.00 


1.00 


5.00 


5 


" 






3240 


6 


12 


63 


1*4-2 hrs. 
l%-2 hrs. 


64 


16 


3.00 


7.00 


1.00 


5.00 


2 


" 






3240 


6 


12 


64 


64 


16 


3.00 


7.00 


1.00 


5.00 


2 


" 






3270 


6 


13 


65 


l%-2 hrs. 
13|-2 hrs. 


64 


16 


3.00 


7.00 


1.00 


5.00 


2 


" 






3270 


6 


14 


68 


64 


16 


4.00 


7.00 


1.00 


5.00 


2 






3300 


6 


15 



At six months weighed 7080 grammes (14 pounds 12 ounces) and was taking 150 c.c. 



abator of an Infant Premature at Thirty Weeks. 



Pulse. 



°F. 



102.5 
99.5 



98.8 



101 



98 

99.5 
101.5 
100 

98.5 



99 

98 

99.5 

99.5 

99 

99 



120 
120 



140 



Resp. 



60 



40 



Temperature 

of 

Incubator. 



Remarks. 



°C. 

32.2 



32.2 
32.2 
32.2 
32.2 

28.3 

26.6 

26.6 

26.6 
26.6 
26.6 
26.6 
26.6 

28.8 

28.8 
29.4 



28.3 
28.3 



°F. 



90 



Nails formed. No lanugo. 
Cry feeble. 



Heart normal. Lungs normal. Emaciated. 



Uric acid on napkin. Food heated to 75° C. (167° F.). 

Somnolent. 

No uric acid. Fed with dropper. 

Temperature went up in evening. Perspired freely. Temperature of 

incubator lowered to 28° C. (85° F.). Hiccough relieved by brandy. 
Respirations irrregular ; 10 quick and thea imperceptible for 10 seconds. 

Cord fell. Somnolent. 
Crv a little stronger. As still perspiring a little, temperature of incubator 

reduced to 26.6° C. (80° F.). 
Slight ophthalmia neonatorum. Icterus neonatorum. Black cloth over 

lid of incubator. 
Somnolent. 
Less icterus. 
Hiccough. 

Hands and feet cold. 
Hands and feet warmer. Oxygen in fresh-air box for 10 minutes three 

times daily. Seems hungry. 
Every other feeding takes i% drachms. Oxvgen as on 13th. 
Oxygen as on 13th. 
Oxygen 5 minutes twice daily. Feet cold when incubator below 29.4° C. 

(85° F.). 

Less icterus. 
Oxygen. 

Very hungry. Oxygen. 

Oxygen. 
Occasional cvanosis. 



Oxygen. 



| Brandy 5 drops every two hours. 

j Feet and hands not cold except when temperature of incubator as low 

! as 26.6° C. (80° F.). Seems hungry. 

| Oxygen. Brandy 5 drops three times daily. 

j Brandy 5 drops three times daily. Oxygen. Began to feed with nipple. 

Respirations deeper and more regular. Slight cyanosis. Oxygen. 

\ Oxygen. Brandy 5 drops. 

j Oxygen. Brandy 5 drops every other feeding. 

Allowed to have a little light in incubator. Omit oxygen. 

Oxygen. Brandy. Somnolent. 

No light. 

Is brighter. Oxygen. 

Oxygen. Brandy. 
Seems stronger. More light. 
Oxygen. 
Brandy. 
Seems hungry. 
Oxygen. 
Omit oxygen. 

Sleeps and takes food well. Seems stronger and brighter, and is tranquil. 
Does not cry. 

Very bright and tranquil. 

Taken out of incubator. Cried9hours. Vomited. Put Lack into incubator. 



Tranquil. Does not cry. 

Taken out of incubator and washed in water at 35° C 
Sleeps well. Does not cry. Is growing stronger 
Thriving. Brandy omitted. 



(95° F.). 



each meal. Looked bright, had a good color, and was well developed and vigorous. 



PREMATURE INFANTS. 281 

with ; but the nurse was possessed with the idea that it needed plenty of cold fresh air. 
The window in the infant's room was left open one night when the weather was quite 
cool. The following day it did not take its food well, was somewhat cyanotic, and was 
found to have lost almost 240 grammes (J pound). It was then placed, as it should have 
been in the beginning, in a warm room, treated with the utmost care, and not handled 
much. None of these measures, however, were sufficient to prevent a still further les- 
sening of its vitality. It never rallied from the first blow which was struck at its 
vitality, and lost its life practically through the ignorance of the nurse who was in 
charge of it. 

A post-mortem examination showed nothing abnormal, except that the mesenteric 
glands were somewhat enlarged. 

The next case was that of an infant born at about the twenty-fifth week of intra- 
uterine life. Its weight was 1080 grammes (about 2\ pounds). There were a number 
of interesting points to be recorded in this case. 

It was not strong enough to suck, and had to be fed with a spoon. Its mother's 
milk, the analysis of which is given below, at once caused such disturbance that modi- 
fied milk from the laboratory had to be substituted. 

{Mother's Milk.) 

Fat 1.29 

Sugar 4. 10 

Proteids 6.83 

Mineral matter 0.26 

Total solids 12.28 

Water 87.72 

100.00 
The prescription for the modified milk which it digested well was 

Prescription 50. 

Modified Milk. 

R Fat 1.00 

Sugar 3.00 

Proteids 0. 75 

The infant's temperature in the rectum was 36.7° C. (98° F.). It seemed to be 
doing fairly well, but did not gain in weight, and on the fifth day of its life was unable 
to swallow. It was then fed by gavage. 

It was treated with great care so far as keeping it warm was concerned, but an in- 
cubator could not be obtained for it, and it died when it was seven days old. 

It is interesting in this case to notice that the meconium came as is usual in the 
infant at term, and began to change its color on the third day, and that by the fifth 
day the faecal movements were yellow and well digested. 

Table 60 records the details of an infant's life in an incubator during 
a period of sixty-four days. This record will be of great use to any 
one who has charge of a premature infant in an incubator, as it illus- 
trates exactly what emergencies are likely to arise and how they can be 
met. 

The infant, as is seen by referring to the column of remarks, came very 
near dying a number of times, and unquestionably would have died had 
it not been carefully managed, as, for example, by the administration of 
oxygen, by prompt changes in its food, by the regulation of the tempera- 
ture of the incubator, and by the constant attention of a day nurse and a 
night nurse. 



DIVISION V. 

DISEASES OF THE NEW-BORN. 



Before entering into a description of the individual diseases of the 
new-born, it will be profitable first to consider some of the general aspects 
of disease as it occurs in early life. 

Disease in General. — The peculiarities which characterize disease in 
children are mostly limited to the period of infancy and the early and 
middle periods of childhood. In later childhood, that is, after the eighth 
or ninth year, disease, both in its etiology, pathology, symptoms, and prog- 
nosis, resembles closely that which is met with in adult life. 

In the earlier periods of life, on the contrary, we meet with distinct 
differences, depending partly on the great role which congenital diseases 
play in the various stages of development and partly on the greater vul- 
nerability of the growing tissues and their lessened power of resistance 
not only to the known specific infections but to numberless as yet undif- 
ferentiated varieties of pathogenic micro-organisms, which are as yet but 
little understood. 

Inheritance. — A very important element to be taken into considera- 
tion as influencing the tendency to disease is inheritance. The occurrence 
in the parents of such diseases as tuberculosis, rheumatism, and the various 
neuroses seems to render the tissues of the children not only more recep- 
tive to these conditions but to so vitiate them that they are readily affected 
by many other diseases. The direct inheritance of such diseases as syph- 
ilis and the great mortality arising from them are distinctly characteristic 
of disease in infancy. 

Malformation. — The greater number of diseases and the greater ten- 
dency to disease in early life, as compared with a later period, is caused in 
large measure by a lack of normal intra-uterine development, resulting 
in malformations, each representing a disease in itself and each having 
such influence on the tissues in general that they become abnormally re- 
ceptive to many diseases. These malformations, such as of the mouth, 
nose, bladder, and rectum, are of especial significance from a surgical point 
of view, while those which are of especial interest to us medically are 
malformations of the heart and brain and such conditions of arrested de- 
velopment as are represented by atelectasis. 

Traumatism. — A class of diseases distinctly infantile is represented 
by traumatic causes, such as certain forms of meningeal hemorrhages, 

282 






DISEASES OF THE NEW-BORN. 283 

abrasions occurring during delivery, which afford, as in the case of an un- 
healed umbilicus, a ready entrance for the micro-organisms of tetanus and 
of erysipelas. The various forms of ophthalmia neonatorum must be in- 
cluded in this class of affections. 

General Etiology. — In addition to the congenital causes of infantile 
disease just enumerated the etiology of the acquired diseases of early life 
is of great interest and importance, for there is no doubt that most of the 
diseases of early life are the direct result of the ignorance or neglect of 
those who have the charge and direction of infants during this period. 
The chief etiological factors of disease in infancy are improper food and 
unhygienic surroundings. These conditions may cause such specific dis- 
eases of nutrition as rhachitis, scorbutus, and infantile atrophy, or may 
result in such a marked degree of malnutrition that there is a decided 
predisposition to various acute diseases such as those of the gastro-enteric 
tract and of the lung, and, later, to such neuroses as chorea and many 
functional disturbances. 

General Pathology. — The pathological processes which occur in early 
life, as distinctive from a later period, are essentially acute, the chronic 
morbid processes, except those which result from acute disease, being rare. 
Hyperplasia of the lymph-nodes and their susceptibility to infection of all 
kinds, together with their great activity in carrying infection, are a charac- 
teristic feature of infantile pathology. 

A series of 726 consecutive autopsies made at the New York Infant 
Asylum and tabulated by Holt, shows the relative pathology of the differ- 
ent organs. None of these autopsies were under one month, 72 per 
cent, were under one year, and only 3 per cent, were over two years. 

According to these figures the lungs first and the intestine second 
were found affected in the greatest number of cases, and it was noted 
that it was rare to find the lungs normal after any acute infectious disease 
had lasted a week. Out of the above-mentioned 726 cases, pathological 
conditions were found in the lung in 399 cases ; of these, 322 were cases 
of pneumonia, of which 139 were primary and 56 were tuberculous. 
There were 6 cases of congenital atelectasis, 1 case of serous pleurisy, 5 
cases of empyema, and although there was dry pleurisy in nearly all the 
severe cases of pneumonia, there was no case of pleurisy uncomplicated 
by disease of the lung. The gastro-enteric tract was affected in 189 cases; 
of these, 116 cases were acute ileo-colitis with or without gastritis. There 
were no cases of gastritis without intestinal lesions. There were 72 cases 
of acute diarrhoea without gross lesions. There was one case of intussus- 
ception. The brain and meninges were affected in 35 cases, of which 11 
were tubercular meningitis. There were 26 cases of malnutrition without 
gross lesions. The kidneys were affected in 26 cases, 7 of which were mal- 
formations, and only 5 cases were primary. The heart was affected in 6 
cases ; of these, 3 were congenital malformations, 3 were pericarditis, all 
occurring in cases of pneumonia, and there were no cases of acute or 



284 PEDIATRICS. 

chronic endocarditis. The peritoneum was affected in four cases. The 
mouth was affected in one case (noma). 

It thus appears that pathological conditions of the liver and spleen are 
rare in early life, as are primary disease of the kidneys and organic disease 
of the brain itself. New growths are rare, and, when present, are usually 
of the kidney or bones. Diseases of the bones and joints are very com- 
mon, and are usually tubercular or syphilitic, more commonly the former* 
Diseases of nutrition are extremely common. 

General Symptoms. — The clinical picture of disease in older children 
does not present many features different from what is seen in the adult. 
In infancy and early childhood, however, there are many differences. 
The infant cannot express its thoughts and sensations in words, and in 
place of this indicates its discomfort by cries and various movements. 
In addition to this, the nervous system is in so sensitive a condition and 
in such unstable equilibrium that its manifestations in disease are very 
misleading. In disease of the lung, for instance, the young child is very 
apt to locate its discomfort in the abdomen, while gastric distention may 
be symptomatically represented by marked pulmonary symptoms. Cere- 
bral symptoms which would at a later period point towards organic 
lesions of the brain or its meninges, often in early life simply indicate a 
disturbance of the meningeal circulation which may arise in almost any 
disease with a heightened temperature or with interference with the circu- 
lation, as in pertussis, in cardiac disturbance, and in acute gastro-enteric 
disease. The reverse of this picture is at times seen in cases of consider- 
able pleuritic effusion with displacement of the heart, in which very slight 
rational signs, in comparison with the same condition in adults, are shown, 
the child appearing fairly well and inclined to run about its nursery. 
Again, with very slight lesions in the lungs, mopt violent pulmonary 
symptoms may arise. An insignificant disturbance of digestion may pre- 
sent most alarming symptoms of pallor and collapse. Infants and young 
children may, from purely nervous causes, vomit so continuously that the 
symptoms, when the vomiting has ceased, closely simulate a typhoid con- 
dition, and, still more frequently, tubercular meningitis. 

The prodromal symptoms of many diseases, both benign and malig- 
nant, simulate each other so closely in early life that the diagnosis must 
often be left in abeyance for many days longer than would be necessary 
at a later period. Pulmonary, gastro-enteric, and cerebral diseases fre- 
quently show this correspondence of symptoms. Affections of the ear, 
where the aural symptoms are marked, as they often are, produce a great 
variety of symptoms pointing towards other organs, such as cough and 
vomiting, and owing to the late closure of the petrosquamosal suture, the 
most pronounced cerebral symptoms. The rational indications of a dis- 
ease, therefore, in early life are a symptom-complex, and we have to rely 
almost entirely on our physical examination. It must be remembered, 
however, that seemingly grave and alarming symptoms do not neces- 



DISEASES OF THE NEW-BORN. 285 

sarily indicate a serious disease, while mild and unobtrusive symptoms 
may be the beginning of a fatal disease. 

Of especial importance in infantile symptomatology are the cry, the 
facial expression, the posture, and the movements of the body ; these 
will be described when the various diseases are spoken of. 

General Diagnosis. — It has already been stated that the diagnosis in 
children is most satisfactorily made by the physical signs, but the examina- 
tion is often so difficult to obtain that we necessarily also depend greatly 
on the history given by the parents and on inspection. There are, how- 
ever, certain methods of examination which are preferable to others and 
which differ in their system from those which we employ in adults. The 
employment of these methods, though involving more time, render it 
possible to obtain a satisfactory examination in almost every case. 

General Prognosis. — The mortality in early life is greater in inverse 
proportion to the age, so that the prognosis in diseases which in older 
children would be regarded as benign should in the early weeks and 
months of life be considered as serious, and the prognosis should be cor- 
respondingly grave. On the other hand, certain organic diseases, such as 
those of the kidney and heart, which would be attended with a very bad 
prognosis in later life, in childhood are much more likely to recover, on 
account of the wonderful recuperative powers of children due to their 
rapid reconstructive metabolism. 

Young children may die after a few hours' illness apparently from their 
lack of power to resist the onset of various infections, such as scarlet fever 
and pneumonia, before these diseases have declared themselves by their 
characteristic symptoms. Sudden death from various and obscure causes 
is also not very uncommon in weak infants who are suffering from mal- 
nutrition. Internal hemorrhages, as in Buhl's disease, asphyxia from 
many causes, sudden collapse in the course of pertussis, laryngospasm, 
or cardiac disease, may also be the cause of sudden death. 

Maternal Impressions. — A few words should be said concerning the 
subject of maternal impressions. For many years there has been accumu- 
lating a considerable amount of evidence showing that a violent mental 
impression made upon a woman who is at the time carrying a child may 
be followed by a physical or mental defect in the child which bears a 
striking relation in character to the impression made upon the mother. 
Thus, Sir Walter Scott narrates that King James the First could not endure 
the sight of a drawn sword. This feeling had been attributed by those 
who believe in maternal impressions to the terror which his mother ex- 
perienced at witnessing the murder of Rizzio. Still more numerous are 
the facts adduced to prove that bodily defects, such as harelip, club-foot, 
and hairy mole, may be caused by strong impressions of pain or terror 
experienced by the mother at the time when the foetus is in a certain 
stage of intra-uterine development. Interesting as these instances are, it 
is the general belief that nothing more has been proved than that they 



286 PEDIATRICS. 

depend on a coincidence. The final decision on this obscure subject 
must rest on future investigation, and until something more definite is 
known we should guard a woman during her pregnancy from all unpleas- 
ant impressions with far more care than we do at present. 

The diseases which we speak of as diseases of the new-born are distinct 
from those which are acquired later in life, in that they represent in almost 
every case an arrest of the normal development which should occur during 
intra-uterine life. A stage of development which is normal at a certain 
period of intra-uterine life becomes abnormal if it persists to a later 
period, and this persistence of an early stage of development constitutes 
in the great majority of cases what is known as congenital malformation, 
Such a failure of development may be the result of intra-uterine inflam- 
mation, which, either by crippling the various functions or by arresting 
the normal intra-uterine growth, produces a condition of disease at birth. 
In many cases, however, the causes are so obscure as to elude our usual 
methods of examination. Diseases of the new-born may also be made to 
include certain abnormal conditions which arise immediately after birth or 
in the early days of life. 

Although many of these affections must pass into the hands of the 
surgeon for treatment, yet it is very important for the medical practitioner 
to be able to recognize at once their true nature and their significance. 
For purposes of simplicity, these diseases can be classified into diseases of 
the head, diseases of the neck, diseases of the trunk, diseases of the extremities, 
and general diseases. 

DISEASES OF THE HEAD. 

Caput Succedaneum. — The normal average head at birth may be 
misshapen from various causes. Of the conditions which may cause 

unusual appearances, the most common is 
Fig. 70. called caput succedaneum, a case of which is 

represented in Fig. 70. 

This infant, a male, two hours old, presented 
a swelling over the right parietal bone extending 
back to the occiput, causing an irregular tumor 
and a great increase in the anteroposterior diam- 
eter of the head. The tumor did not fluctuate. 
The presentation was occiput left anterior, and 
no instruments were used. The swelling corre- 
sponded to the place where there was the least 
pressure, — that is, the presenting part. 

It is needless to say that this caput suc- 
cedaneum requires no treatment, as it 
gradually disappears of itself by absorp- 
tion in a few days. It is simply a swelling of the scalp caused by a 
passive congestion with extravasation of blood and lymph into the 
connective tissue external to the pericranium. 




Caput succedaneum. Male, 2 hours 
old. 



DISEASES OF THE NEW-BORN. 



287 



Caput succedaneum must be carefully distinguished from another 
swelling of the scalp, cephalhematoma, which may occur in connection 
with it, and which appears as the caput succedaneum disappears, 

Cephalhematoma. — During labor a hemorrhage may take place from 
the blood-vessels of the head which gives rise to a tumor in one of three 
situations : (1) between the occipito-frontalis aponeurosis and the perios- 
teum ; (2) between the periosteum and the skull ; or (3) between the 
skull and the dura mater. The first two are known as external cephal- 
hematoma, the last as internal cephalhcematoma. The cause cannot be en- 
tirely from pressure over the presenting part, as the lesions have been 
found in breech presentations. 

Cephalhematoma is distinguished from caput succedaneum by its sharp 
limitation to one of the parietal bones, by its fluctuation, and, if seen late, by 
its surrounding bony wall. Cephalhematoma usually develops after birth, 
while caput succedaneum is present at birth. It can be diagnosticated posi- 
tively by the withdrawal of some of the fluid by a hypodermic syringe. 
Another condition which may simulate it somewhat is a depressed fracture. 
The differential diagnosis from this latter condition can best be made by 
remembering the fact that the resistant rim of the cephalhematoma is 
raised above the level of the surrounding 
bone, and is somewhat compressible, while 
on the inside it can be felt to slope evenly 
towards a fluctuating centre. In fracture 
no such arrangement occurs. 

(a) External Cephalhematoma. — By far 
the most common form is that in which 
the tumor has formed between the skull 
and the periosteum. It shows itself as an 
irregular circular swelling over a parietal 
bone, and gives on palpation a distinct 
feeling of fluctuation. The skin over it is 
not discolored or reddened. In the cases 
that have existed for a few days a bony 
wall can be felt surrounding the tumor, 
the edges of which give a crackling sensa- 
tion under the finger. In this stage it 
may strongly suggest a fluid tumor coming 
through a circular hole in the skull. 



Fig. 71. 




Double cephalhematoma. Infant, 4 days 
old. 



Fig. 71 represents a case of double cephalhematoma of the external variety ; that 
is, it is an extravasation of blood under the pericranium. Its base corresponded to 
the denuded bone, and was oval or circular. There were bulging tumors on each side 
of the sagittal suture with a deep sulcus between them. 



Treatment. — Treatment designed to promote absorption should be 
avoided. The part should be protected from injury. Absorption usually 
occurs in the course of a few weeks. 



288 



PEDIATRICS. 
Fig. 72. 




Double external cephalhematoma. Both parietal bones. Warren Museum, Harvard University. 

Pig. 73. 







External cephalhematoma. Parietal bone dissected. "Warren Museum, Harvard University. 



DISEASES OF THE NEW-BORN. 289 

Fig. 72 represents the dried preparation of a double cephalhema- 
toma which is in the Warren Museum. 

On the left side of the skull (the right side of the picture) the integu- 
ment has been nearly removed, showing a raised bony rim. 

On the right side of the skull (the left side of the picture) the integu- 
ment has been cut off and partially deflected, showing the cavity which 
contained the diffused blood. 

Fig. 73 is a parietal bone dissected so as to show the condition of 
the bone in a case of external cephalhematoma. 

The specimen shows well the raised rim and the porous condition of 
the bone underlying the tumor. In two or three places the bone sub- 
stance has entirely disappeared. 

(b) Internal Cephalhematoma. — Internal cephalhematoma is situated 
between the inner surface of the skull and the dura mater, and is rare. 
It is at times found in connection with the external variety. 

The prognosis in these cases is bad. They are usually fatal, and there 
is no known treatment which can save them. 

Meningocele. — By the term meningocele is understood a protrusion 
of some part of the membranes of the brain through a hole left in the 
cranial wall by defective ossification. In some instances this is caused by 
an intra-uterine hydrocephalus. These tumors generally contain some 
of the cerebro-spinal fluid in the bag of membrane. Such fluid can often 
be reduced into the skull by gentle pressure, but at the risk of bringing on 
symptoms of cerebral disturbance, an important point in differentiating 
the condition from cephalhematoma. 

Fig. 74 represents a small meningocele above the left ear about 2.5 cm. (1 inch) 
in diameter. Some fluid was withdrawn from it by an aspirating needle, and the con- 
tents of the sac proved to be serous without cells. The sac refilled after tapping. No 
more extensive operation on it has so far been undertaken. The child was rhachitic. 
It had a fall some time previous and struck its head. Nothing abnormal was noticed 
about the child previous to the fall, but after the ac- 
cident a swelling appeared above and behind the ear. Fig. 74. 
The swelling increased in size when the child cried, 
was soft, fluctuating, and not tender. The knee-jerks 
and sensation were normal. The ophthalmoscopic 
examination disclosed nothing abnormal. 

A much more serious condition is shown 
in the meningocele in the following case. 

The infant was two weeks old when operated 
upon. Behind its left ear was an irregular tumor 

about 7.5 cm. (3 inches) long. The ear was pushed Meningocele. Female, 3 years 

forward, and appeared to be growing from the tumor. old. 

The labor was normal, and the infant at birth was 

perfectly healthy and well formed, except for the tumor, which was congenital. On 
examination the tumor was found to be fluctuating and translucent. There were large 
veins on its surface. No impulse could be felt on crying, nor did pressure cause any 

19 




290 PEDIATRICS. 

cerebral symptoms. On aspirating it, 45 c.c. (1J ounces) of a clear reddish fluid were 
withdrawn. This fluid contained red blood-corpuscles and a few endothelial cells. No 
unfavorable symptoms followed the aspiration. After the withdrawal of the fluid two 
openings could be felt, the anterior of which probably connected with the external audi- 
tory meatus. The tumor was increasing in size so rapidly that an operation was decided 
upon. On removing it an opening in the skull large enough to admit two fingers was 
found. The child made a rapid recovery from the operation, and was left with only a 
scar behind the ear. There were no cerebral symptoms. During convalescence the 
child seemed to be mentally bright. 

Encephalocele. — Still more common than the pure meningocele is 
that condition in which the hernia contains some of the cerebral sub- 
stance as well as the membranes. This condition is called encephalocele ; 
or if, as is often the case, it contains a portion of a dilated ventricle, so that 
the tumor is filled with cerebro-spinal fluid, it is known as hydro-encepha- 
locele or as hydro-encephalo-meningocele. 

Fig. 75 represents a remarkable case of hydro-encephalocele which 
was treated by Dr. Lovett in the hospital. 

The infant from the time of its birth had tonic and clonic convulsions, occurring 
usually as often as once in three hours. It was brought to the hospital when it was 
two months old. It was well formed in every way, except that it had a tumor on the 
back of its head which was at least one-third as large as its skull. The tumor was 
only partly covered with skin, the upper part of it being a thin translucent membrane. 
It communicated with the brain through a large square hole in the back of the skull. 
The tumor fluctuated slightly and appeared to be a multilocular cyst, for when it was 
aspirated only a part of the contained fluid could be withdrawn. The tumor was 
removed by Dr. Lovett and the wound sewed up tightly. The cyst was found to con- 
tain a viscous fluid with slight flakes in it which proved to be particles of cerebral 
substance. The convulsions immediately became less frequent, and ultimately on 
treatment with bromide of potash disappeared almost entirely. 

The infant in other respects was very little affected >y the operation, and recov- 
ered rapidly. After remaining in the hospital two weeks it was taken to its home, 
where it died some months later of some intercurrent affection. 

Regarding these tumors in general, it is enough to say that we should 
view with suspicion any fluctuating swelling that seems to have a deep 
attachment in the neighborhood of one of the cranial sutures. The" most 
frequent seat of these tumors is in the occipital region and at the root of 
the nose. Their treatment has not proved very successful. Some few 
may steadily decrease of themselves and ossification may block up the 
abnormal opening. Pressure and the injection of Morton's fluid have 
both been tried, and in some cases have been attended with success. 
At present the operative plan of treatment is considered the best. With- 
out interference the tendency is usually towards rupture of the hernia, 
convulsions, and death. 

Anencephalia. — The cerebro-spinal system is formed from the medul- 
lary tube, which is made by the infolding of epibiast along the medullary 
groove : if the formation of the medullary tube is for any reason incom- 
plete, or if the dorsal wall of the tube is destroyed, the cerebrum or part 



DISEASES OF THE NEW-BORN. 



291 



of the cerebral axis will remain rudimentary. According to the amount 
of interference with the development we may find more or less of the 
brain remaining in a rudimentary condition, and thus producing greater 
or less degrees of what is called anencephalia. Total anencephalia is 
rare. Partial anencephalia is much more common. These cases are not 
of especial interest, as it is exceptional for them to live beyond a few days. 
Congenital Hydrocephalus. — One of the more common malforma- 
tions of the head is a hydrocephalic condition at birth, called congenital 
hydrocephalus. It is described on page 970. 



Fig. 75. 




Female, 2 months old. Hydro-encephalocele. 



Harelip. — If the maxillary process on one or both sides of the face 
fails to unite with the intermaxillary process, a cleft will remain open in 
the contour of the upper lip on one or both sides of the intermaxillary 
bone, and hence we shall have single or double harelip as the case may 
be. If the cleft extends the whole distance from mouth to nostril it is 
called complete, but if the nostril is not reached by the opening it is called 
partial harelip. If there is a failure of the palatine processes to join, one 
or both nostiils will open into the roof of the mouth as well as into the 




292 PEDIATRICS. 

pharynx, and we shall have the malformation known as cleft palate. 
This may be a large chasm running the whole length of the roof of the 
mouth, or may be only a small opening, or nothing but a bifurcation 
of the tip of the uvula may be left to show that the normal process of 
development has not gone on to completion. 

Besides their unsightly appearance, 
which always causes the mother great 
concern, these malformations may so 
interfere with the infant's taking the 
breast as to render sucking impossible 
and make it necessary to feed the in- 
fant with a spoon. 

Fig. 76 represents a typical case of dou- 
ble harelip uncomplicated by cleft palate. 

The intermaxillary bone was of a large 
size, protruded considerably beyond the mar- 
gin of the lips, and was somewhat twisted 
upon itself. This alteration of the position 
of the intermaxillary bone may cause the teeth that grow from it to appear in very 
unusual places, so as to protrude, for instance, from the nostril. 

The operation should be performed during the early weeks of life, 
as the growth of the facial muscles is not then sufficient to interfere with 
the healing of the wound. 

There is considerable difference of opinion as to when cases of con- 
genital harelip should be operated on. In general, it can be said that 
cases of single harelip unassociated with cleft palate can be operated on 
from three to six weeks after birth, while the severer forms are best left 
for as many months. When the infant is wasted and is in a poor general 
condition, the indication is to postpone the operation, as it is seldom 
that this defect is the cause of the general lack of proper development. 

Cleft Palate. — In speaking of harelip most of the conditions occur- 
ring in cleft palate have been described. The difficulty of feeding, if the 
cleft involves the hard as well as the soft palate, is very great, and can 
best be accomplished with a spoon. The difficulty in articulation and 
tne unpleasant sound of the voice are reasons which lead the parents to 
demand early treatment. We should wait a longer time before operating 
than in cases of harelip, as it is seldom wise to operate upon this deformity 
before the child is three years old. The operation for cleft of the soft 
palate is called staphylorrhaphy, and that for the closure of a cleft in the 
hard palate is termed uranoplasty. The larger the opening in the palate 
the more successful will be the treatment by apparatus in comparison 
with that by the knife, and many prefer to close the cleft by fitting artifi- 
cial plates. 

Tong-ue-Tie. — In quite a number of cases the fraenum of the tongue 
is abnormally short at birth. In extreme cases the tip of the tongue is so 



DISEASES OF THE NEW-BORN. 293 

closely bound to the lower jaw that it cannot be protruded beyond the 
line of the gum or touched to the roof of the mouth. The mother usually 
notices that the infant does not nurse readily, and brings it to the physi- 
cian to discover the cause. In most cases on passing the finger into its 
mouth the infant is found to suck fairly well ; but there can be no doubt 
that this condition, which is called tongue-tie, interferes somewhat with 
the process of sucking. 

Children who have not learned to talk at the usual time in the second 
and third years are frequently brought to me with the statement that they 
are tongue-tied, and the parents wish the condition to be treated. Large 
numbers of children are taken to the physician under this supposition 
but in very few instances are they tongue-tied. These children belong to 
the class of retarded speech. The condition is a central one of the 
brain, and not a local one in the mouth, and if children hear well and 
are bright and mentally well developed, even though they do not speak 
at the third, fourth, or even fifth year, as a rule they learn to speak 
later. 

Treatment. — The treatment is to cut the frsenum. This operation 
should be followed by no hemorrhage and requires no dressing. Having 
the child's head held in a fairly good light by an assistant, and guarding 
the lower part of the tongue with the perforated flange of a director, a 
small cut is made in the tense fraenuni with a pair of blunt-pointed 
scissors. By making the cut close to the gum there is no danger of 
wounding the ranine artery. The cut is prolonged as far as is necessary 
by tearing with the finger-nail. 

Ranula. — Beneath the tongue we sometimes find the mucous mem- 
brane bulging out as a bluish, translucent tumor which is soft, painless, 
and semi-fluctuating. This condition is called ranula, and is a retention 
cyst caused by the blocking of a mucous duct. When opened, a small 
amount of glairy fluid escapes, but the collapse of the walls of the cyst 
brings the edges of the cut together and they quickly adhere. The fluid 
will soon re-collect ; therefore the only sure way of dealing with these 
cysts is to pinch up their anterior wall with fine forceps, and with the 
scissors remove so much of it as to leave no opportunity for the edges to 
adhere. A gentle application of nitrate of silver to the edges and interior 
of the sac after the cut has been made with the scissors materially helps 
to promote the cure. It is not common in new-born children, but it 
occurs often enough to deserve mention. 

Protrusion of the Bars. — A deformity which is quite frequent at 
birth, and which increases as the infant approaches childhood, is the pro- 
trusion of the ears. The ear, besides at times being placed in an irregular 
position on the head, has in these cases a tendency to stand out from the 
head farther than is considered normal. This position of the ear usually 
annoys a mother very much, and the physician will frequently be con- 
sulted as to the means by which the deformity may be rectified. 



294 PEDIATRICS. 

Treatment. — In a large number of cases the persistent application of 
pressure by means of various devices, one of which is a fenestrated cap, 
will cause the ears to be flattened against the side of the head. In intract- 
able cases an operation will have to be performed, but it is very simple 
and does not leave an unsightly scar. 

Ophthalmia Neonatorum. — Ophthalmia neonatorum has been divided 
into two forms, the catarrhal and the purulent. 

(a) Catarrhal Ophthalmia. — The catarrhal form may be caused by any 
slight irritation of the eyes of the infant. It runs a very mild course, the 
inflammation attacking chiefly the palpebral conjunctiva. Often the only 
symptoms noticed are a slight photophobia and a collection of the secre- 
tion in the angles of the lids and upon their borders. Its whole course is 
mild, and often it is all over in a few days. 

(6) Purulent Ophthalmia. — Although a considerable number of .causes 
for purulent ophthalmia in the new-born have been given, such as trauma, 
exposure to light and cold, and others, certainly ninety-five per cent, of 
all cases are caused by infectious material from the genito-urinary tract 
of the mother, and in most instances by gonorrheal pus. The early 
signs of the disease may appear at any time from the third hour of life, 
and the earlier the pus appears the more virulent will be the course of 
the disease and the more unfavorable the prognosis. If infection takes 
place during the birth of the child, the symptoms usually begin on the 
third day ; but, as contaminated linen and fingers may carry the infectious 
material to the infant's eyes at a later period, the symptoms may be 
delayed indefinitely. 

Symptoms. — The disease begins as a redness of the conjunctiva, with 
a slight discharge from the corner of the eye. This is succeeded with 
startling rapidity by intense inflammation of the lids. In twenty-four 
hours the upper lid may become so much swollen as to overhang the 
cheek and render opening the eye impossible. On separating the lids, a 
little greenish pus, which may even be tinged with blood, wells up between 
them. At first the cornea is unaffected, but if the pus accumulates under 
the oedematous lids it soon shows signs of ulceration. In the second 
twenty-four hours the ulceration may perforate the cornea and evacuate 
the aqueous humor, thus bringing the iris into contact with the posterior 
surface of the cornea. The inflammation may extend around the eye 
and well over the forehead and malar prominence, but it does not persist 
in the latter region very long. All the symptoms disappear slowly, and 
recovery takes place, except in those cases in which the cornea has been 
permanently injured by ulceration. 

Treatment. — In treating this disease we must be very prompt and 
energetic. It often may be averted by what is known as Crede's method. 
This consists in dropping one or two minims of a two per cent, solution 
of nitrate of silver into each eye of the new-born infant. Although this 
has been known to cause even a considerable amount of irritation, yet it 



DISEASES OF THE NEW-BORN. 295 

undoubtedly exerts a powerful influence in warding off this dangerous 
disease. 

After the disease has once begun, two indications must be kept in 
mind: (1) to reduce the inflammation, and (2) to prevent the pus from 
accumulating behind the tightly closed lids. By far the best way of apply- 
ing cold to the eye is by compresses of thin, soft pieces of linen cut into 
small squares. Not more than two thicknesses are to be used at once. 
These compresses are to be cooled by laying them on a piece of ice or 
floating them in ice-water. They must be constantly changed. To re- 
move the pus, a gentle irrigation, such as can be easily obtained by using 
a medicine dropper, is sufficient. 

The secretion is highly contagious, not only for the infant's other eye, 
but for those who are taking care of it. Therefore one must avoid all 
spattering, and should cover the infant's well eye before beginning the 
irrigation. 

In the irrigation of the eye one should first turn the child's head a 
little to the diseased side, and with the fingers of the left hand gently 
separate the lids as far as possible. Then, holding the dropper with the 
right hand, irrigate between the lids, directing the stream from the nose. 
After each irrigation vaseline should be applied to the edge of the lids. 
This should be done at least every half-hour, day and night, until the 
swelling has so far subsided as to preclude the danger of any secretion 
being retained. For irrigation many solutions have been advocated. 
The most simple, and perhaps the best, is a saturated solution of boracic 
acid, or one of bichloride of mercury in the strength of 0.05 gramme 
(1 gram) to 480 c.c. (1 pint) of distilled water. In the later stages of the 
disease, where all the tissues are relaxed, a solution of nitrate of silver, 
0.5 gramme (10 grains) to 30 c.c. (1 ounce) of distilled water, may cau- 
tiously be used once a day. This same solution painted on the conjunc- 
tiva with a camel's-hair brush once daily early in the disease is very 
effective in shortening the course of the disease. 

DISEASES OF THE NECK. 

Haematoma of the Sterno-cleido-mastoid Muscle. — During the birth 
of the child, either from the violence of the expulsive efforts of the 
uterus, or, as more frequently happens, from the pressure of the forceps 
in head presentations, or from too vigorous traction upon the feet in 
breech presentations, or for no assignable reason, the sterno-mastoid 
muscle may be partially ruptured in its sheath and a haematoma form be- 
tween the torn ends. This- tumor may be either in the sternal or in the 
clavicular portion of the muscle, or may be just above the junction of the 
two. For a short time it is soft and tender, but gradually it loses its 
sensitiveness and becomes converted into fibrous tissue, which then tends 
to contract. It may appear as a small tumor, but in infants with fat 
necks it may not be noticeable at first. As turning the head towards the 



296 PEDIATRICS. 

affected side lessens the tension upon the swelling, the infant will rigidly 
hold its head in that position. It is in this way that cases of infantile 
torticollis are thought by most writers to arise. 

Treatment. — After the painful stage has passed, the treatment is by 
gentle massage and manipulations addressed to stretching the shortened 
muscle. If these methods fail, the child must be placed in the hands of 
an orthopaedic surgeon for more extended treatment, either by appa- 
ratus or by division of the tendinous attachments of the sterno-mastoid 
muscle. 

Branchial Fistulse. — At an early period of development the neck of 
the foetus has along its sides a series of four branchial clefts, which com- 
municate freely with the oesophagus and represent the gills of aquatic 
animals. The upper one of these forms the tympanum and the eustachian 
tube, the rest are normally obliterated. Sometimes we find traces of 
these branchial clefts in the form of small fistulous tracts which admit a 
probe a short distance and end blindly. Their most frequent seat is 
just above the sterno-clavicular articulation, but they may be found any- 
where along the anterior border of the sterno-mastoid muscle. Some- 
times the entrance of these flstulae becomes stopped, so that they dilate 
and form large cysts containing mucus, blood, and atheromatous detritus. 
These form at times large and unsightly bunches, which require surgical 
treatment. Often the operation of obliterating them is not an easy one, 
for they are apt to have deep and complicated attachments. 

Treatment. — If they do not cause any inconvenience it is better to let 
them alone, as they often prove very intractable to treatment. If they 
are annoying because of a slight mucous discharge, we can try to eradi- 
cate them with the galvano-cautery, or by passing a probe into the wound 
and dissecting from around it the lining of the sinus. 

DISEASES OF THE TRUNK. 

Mastitis. — In certain infants during the early days of life we find a 
swelling and hardness of one of the mammae. This condition appears 
to be an inflammatory one, and is abnormal. In connection with the 
swollen condition of the mamma, a secretion is found to come from the 
nipple which corresponds closely to milk, and which has been called 
"witches' milk." 

A number of analyses have been made of this fluid, and the follow- 
ing are some of them : 

(Sehlossberger. ) 

Fat 0-82 

Casein, sugar, and extractives 2.83 

Mineral matter 0.05 

Total solids -• • 3 - 70 

Water ••••• 96.30 

100.00 



DISEASES OF THE NEW-BORN. 



297 



(Von Gesner. ) 

Pat 1.45 

Casein 0. 55 

Proteids 0.49 

Sugar 0.95 

Mineral matter 0.82 

Total solids 4.26 

Water 95.74 

100.00 

This condition occurs in boys as well as in girls, and, as far as I 
know, has no special significance. With ordinary antiseptic precautions 
the inflammation usually subsides in a few days, leaving the affected 
breast the same size as the other. The following case represents this 
condition of the mamma in a female one week old : 

The swelling of the mamma was noticed on the fourth day of her life. A little 
fluid looking like diluted milk could be expressed from the mamma. The treatment 
of the case was simply to keep it thoroughly clean by washing it with sterilized water, 
carefully drying it, and applying a compress with a little simple ointment on it. 

Depressed Sternum. — There are a great many congenital malforma- 
tions which may occur in different parts of the thorax. Fig. 77 repre- 

Pig. 77 




Congenital depression of sternum. Male, 6 years old. 



sents one of these. It occurred in a boy who was born with a depression 
of the lower part of the sternum. 



He was six years old when first seen, and had a rounded depression, about 4 
cm. (1| inches) in diameter, beginning at the third costal cartilage and extending 
to the ensiform cartilage. He was perfectly healthy. The cardiac dulness extended 
to 2.5 cm. (1 inch) to the left of the mammary line, and its impulse was in the 
fourth left interspace. The spinal column was straight. The epiphyses of the wrists 
were slightly enlarged, but there was no other evidence of rhachitis. When he was 



298 PEDIATRICS. 

two months old he had a severe attack of pertussis, which lasted for over two months. 
At five years of age he had a very severe attack of bronchitis. 

Although this depression of the sternum was present at birth, and later increased 
in depth and in circumference, it eventually ceased to enlarge. The circumference 
of his head and that of his chest was 50.5 cm. (20 inches). The heart was somewhat 
displaced upward and to the left, but was apparently unaffected by its abnormal 
position. Light gymnastic exercises to broaden the chest and to strengthen the 
thoracic muscles were advised for treatment. Such a malformation as this sometimes 
results as one of the changes subsequent to Pott's disease. More often the sternum 
protrudes, but occasionally recession takes place, closely resembling the condition in 
this case. 

Prominent Sternum. — A prominence of the sternum, called pigeon- 
breast, occurs more often than the depression. It may happen without an 
assignable cause, or it may be due to rhachitis, and may also result from 
some spinal distortion, such as that of Pott's disease, or lateral curvature. 
In the latter case the sternum is often tilted to one side. 

Spina Bifida. — Spina bifida consists of a lack of closure of the 
laminae of the vertebrae. This condition is normal at a certain period of 
intra-uterine life, but when persisting to a later period, and when oc- 
curring at birth, becomes abnormal from a developmental point of view 
and represents a distinct malformation. As the fusion of the laminae at 
the base of the spinous process takes place in sequence from above 
downward, the most frequent seat for spina bifida is in the lumbar and 
lumbo-sacral regions. There it appears as a tumor situated exactly in the 
middle line, covered sometimes with healthy skin, but as frequently roofed 
over by nothing but a thin adherent transparent membrane. Rarely the 
tumor is solid, containing nothing but an empty sac that has been Availed 
off from its connections with the spinal canal. It is then called spina 
bifida occulta. In true spina bifida the tumor is filled with cerebro-spinal 
fluid, which can be seen to increase in amount as the child cries, and can, 
by pressure upon the sac, be forced back, in this case often giving rise to 
cerebral symptoms. According to the contents of the tumor, spina bifida 
has been divided into several varieties. 

(a) Spinal Meningocele. — When there is a protrusion of the mem- 
branes filled with fluid the tumor is called a spinal meningocele. 

(b) Meningo-myelocele. — The most common form is where the spinal 
cord, as well as the membranes, is found in the tumor. It then becomes 
a meningo-myelocele. The position of the cord in these tumors is a very 
variable one. It may run directly through the tumor and even be sus- 
pended by a kind of mesentery ; or, as is usually the case, it may be 
spread out like a fan over the surface ; in any instance it is rudimentary 
in character. 

(c) Syringo-myelocele. — Syringo-myelocele is a rare form, in which the 
sac is formed of meninges and cord, the central canal of the cord being 
dilated to make the cavity of the tumor. 

Spina bifida occurs usually in poorly developed infants, and in a large 



DISEASES OF THE NEW-BORN. 



299 



majority of cases it is associated with other malformations, such as con- 
genital hydrocephalus, harelip, club-foot, paralysis of the lower ex- 
tremities, and in severe cases there may be incontinence of urine and of 
faeces. Sometimes the infant is well formed and healthy in every other 
respect. 

If left to itself, the course of spina bifida is in one of two directions : 
(1) spontaneous closure and obliteration of the sac ; (2) ulceration of the 
sac, usually followed by convulsions and death. In the first case, which 
is very rare, the sac shrivels up and thus effects a spontaneous cure. The 
following case was one of spontaneous closure : 

Fig. 78. . 




Spina bifida. Spontaneous cure. Male, 4% years old. 



A boy, four and one-half years old, showed an elevated cicatrix in the lumbar 
region, which suggested the former existence of a spina bifida. The case was seen 
by Dr. Lovett when it was eighteen months old, and so far as could be learned there 
had been a large tumor present at birth. The sac burst in this case, and, contrary 
to the general result, the child did not die, but was left with paralysis of the legs, 
which made it stand in the curious and abnormal position shown in Fig. 78. He 



300 



PEDIATRICS. 



also suffered from incontinence of urine and of faeces. The child had never walked, 
and it seemed probable that his disability was caused by the fact that the nerves 
were spread on the walls of the sac, as is usual in many cases, and that they were 
incorporated in the cicatrix. 

A result such as is described in the above case is, however, very ex- 
ceptional. The rule is, either that there is an ulceration of the sac, fol- 
lowed by a large loss of cerebro-spinal fluid, convulsions, and death, or 
that the opening in the spine being very small the loss of fluid is constant, 
and the result is the same, In some instances there is an infection of 
pyogenic organisms through the walls of the sac, which causes a septic 
meningitis in the cord, and finally in the brain. Such a case has been 
reported and beautifully illustrated by Holt, showing the presence of the 
bacteria and a resulting purulent hydrocephalus. 

Fig. 79 represents another case of spina bifida which will illustrate 
the ordinary course of the affection. 



Fig. 79. 




Spina bifida of dorsal lumbar region. Infant 48 hours old. Died when 10 days old. 

It shows a large spina bifida in the dorso-lumbar region. The membrane cover- 
ing the tumor was so translucent that the spinal cord could be plainly seen through it. 
At birth there was a small tumor. It filled Math fluid at the end of twelve hours, and 
at the end of forty-eight hours it looked as it does in this picture. The top of the 
tumor suppurated, the fluid began to leak away, and the child died within ten days. 

This is the course pursued by the disease in the majority of cases 
which are not operated upon. 



Fig. 80 represents the case of a boy five years old, who had had this large tumor 
since birth. It was situated over the lumbar region of the spinal cord, and in the 
median line. The fluid was withdrawn several times for purposes of examination, 
and when the sac was lax an opening 5 cm. (2 inches) long could be felt in the spinal 
canal. It was elliptical in shape. From the fact that the child suffered from incon- 
tinence of urine and had a certain degree of paralysis of the legs, it was fair to infer 
that the nerve-supply of the legs and pelvis was incorporated in the tumor. 

This case was tapped and treated with an injection of Morton's fluid, but the 



DISEASES OF THE NEW-BORN. 301 

treatment was entirely unsuccessful, and although the sac was aspirated several times 
the fluid always returned. 

Treatment. — The only rational treatment of spina bifida is by opera- 
tion, and the operation now commonly done is excision of the sac and 
closure of its neck. The subsequent development of internal hydrocepha- 
lus is unfortunately not uncommon. 

Fig. 80. 




Spina bifida of lumbar region. Male, 5 years old. 

Rhachischisis. — Rhachischisis is one of the principal forms of con- 
genital defects of the spine. It is characterized by a deficiency of the 
vertebral arches either complete or partial. The cord is rudimentary and 
is split open so that the endothelial lining- of the central canal is exposed. 
This may occur in the whole of the cord or in a part of it, constituting total 
or partial rhachischisis. This disease is of pathological rather than clini- 
cal interest, as the infants die in a short time. 

Phlebitis and Arteritis Umbilicalis. — The cause of both of these con- 
ditions is a septic infection of the umbilical stump. It is considered by 
most pathologists to begin as an inflammation of the perivascular cellular 
tissue, and only secondarily to invade the walls of the vessels. The region 
around the umbilicus is red and hot, and we may be able by gentle press- 
ure to squeeze a few drops of pus from the stump of the cord. It is a 
very dangerous affection, as septic emboli readily pass from the infected 
vessels into the general circulation and set up metastatic inflammation in 
the thoracic as well as in the abdominal organs. 

Treatment. — The treatment is to sustain the infant's vitality by stimu- 
lation and thoroughly to disinfect the umbilicus with solutions of bichloride 
of mercury or carbolic acid, followed by the application of boracic acid 
or iodoform powder. A flaxseed poultice is often of service, and some 



302 PEDIATRICS. 

authors recommend placing the infant upon its abdomen in order that 
gravity may aid in draining away the pus. 

Congenital Umbilical Hernia into the Cord. — Dr. Howard Marsh, in 
the Report of St. Bartholomew's Hospital for 1874, calls attention to the 
" familiar anatomical fact that from about the sixth to the twelfth week 
of intra-uterine life the caecum and neighboring portions of the ileum are 
contained in the part of the umbilical cord which is next to the body of 
the embryo, and that they should subsequently withdraw into the cavity 
of the abdomen. In some cases, however, this recession fails to take 
place, and the intestine remains, even up to the time of birth, still lodged 
in the beginning of the cord, which is dilated in the form of a membra- 
nous sac." Not only may portions of the intestine be thus left outside of 
the abdominal wall, but, as in a case recently operated upon by Warren, 
the liver may be found lying in a hernial sac made from the dilated base 
of the umbilical cord. 

The infant was sent to Dr. Warren at the Massachusetts General Hospital a few 
hours after its birth. At the umbilicus was seen the cord, which was greatly distended 
at its point of insertion into the abdomen, forming a tumor 6.5 cm. (2| inches) in 
diameter. The coverings of the cord were inserted into a raised rim of skin, and were 
opaque, so that the contents of the hernia could not be determined. 

When the infant was one day old, Dr. Warren enlarged the umbilical ring some- 
what, separated the liver from the myxomatous tissue of the cord, which was in some 
places firmly adherent to it, and returned the mass within the abdomen. The wound 
was tightly closed with strong silk sutures. There was considerable shock following 
the operation, but there were no symptoms of peritonitis. In two weeks the wound 
had healed, and the infant recovered. 

Fungus of the Umbilicus. — The umbilical cord, after being ligatured 
at birth, falls off by the seventh or eighth day, leaving a clean, dry cica- 
trix. After the separation of the cord we sometimes find a red protru- 
sion, with a moist surface, that may even have a short central canal. This 
is generally due to an imperfect disintegration of the cord. It may bleed 
very readily if touched, and give rise to a discharge so irritating that the 
skin for some distance around the umbilicus becomes eczematous. This 
condition is called fungus or polypus of the umbilicus. 

Treatment. — The treatment is very simple. The larger ones are best 
removed by ligation ; the smaller ones can be destroyed by the applica- 
tion of nitrate of silver or the actual cautery. 

Meckel's Diverticulum. — A condition which may at first simulate 
umbilical polypus, and of which umbilical polypus may be a symptom, is 
the persistence of a Meckel's diverticulum. This consists of the persist- 
ence of a piece of intestine, usually patent, connecting the small intestine 
with the umbilicus. It represents a vitelline duct that failed to atrophy 
when the placental circulation became established, and betrays its presence 
by an escape of faeces from the umbilicus. It is a rare malformation. 

Umbilical Hernia. — The ordinary umbilical hernia, which is simply a 



DISEASES OF THE NEW-BORN. 308 

protrusion of a knuckle of the intestines through the unclosed abdominal 
opening left by the separation of the cord, is of very common occurrence. 

Treatment. — The lighter grades tend to recover spontaneously, and it is 
not advisable to operate upon them, or in fact on any umbilical hernia, 
until it has proved to be absolutely intractable, for it is an operation 
accompanied by considerable danger to the life of the infant. The lighter 
grades of umbilical hernia are usually easily reduced, but there is often 
great trouble in keeping them so. Various devices are employed for this 
purpose, but most of them are very unsatisfactory. At the Children's 
Hospital we are in the habit of proceeding in the following manner : 

Having gently reduced the hernia, the skin of the abdomen is so 
pushed up between the fingers that it makes a vertical fold, at the bottom 
of which lies the umbilicus. The hole should be deep enough to lay 
one's finger in it. The tension is kept up by applying a wide strip of ad- 
hesive plaster transversely across the abdomen. This makes a pad of 
flesh, which closes the umbilical opening and retains the intestine in place. 
The cure is a slow one, and the treatment must be continued for many 
months in severe cases, without once allowing the hernia to come out. 
The milder cases are also aided by exercises which tend to develop the 
abdominal muscles. This can be very simply effected by having the child 
lie on the floor, and, while the feet are held down, making him rise to a 
sitting position with the back held straight. This is accomplished by the 
rectus muscles of the abdomen, and if the opening is a transverse one it 
tends to close it. 

Fig. 81 represents an extreme case of umbilical hernia in an infant five months 
old. The hernia caused an eversion of the whole umbilical region. 



Fig. 




Large umbilical hernia. Infant 5 months old. 



Cases of incarcerated and even strangulated umbilical hernia have been 
reported, but are very rare. A few have been operated upon successfully. 
The danger from all such procedures is usually considered great, but there 
has been such an advance made in the modern methods of abdominal 



304 PEDIATRICS. 

surgery that the operation is looked upon with increasing favor. Cases 
of hernia, whether umbilical or inguinal, are especially difficult to manage 
if the infant has pertussis or some similar disease. 

Inguinal Hernia. — The most common forms of inguinal hernia that 
occur in young children are (1) the congenital, (2) the funicular, and (3) 
the infantile or encysted. An ordinary acquired form such as is the rule in 
the adult may be met with, but it is not so common. Strangulated and 
incarcerated hernise occur at times, as in the adult, although they are 
rare. 

There seems to be some evidence that the tendency to hernia is 
hereditary. Felizet reports eighty-five cases of hernia occurring in his 
practice, in which, omitting all cases in which the father pursued some 
laborious trade, such as that of a blacksmith, he found that in 24.7 per 
cent, the parents had had similar herniae. Malgaigne reports a percent- 
age of 29 due to heredity in a series of three hundred and sixteen cases 
of hernia. 

Infants are at times brought to our hospitals with a history of colic 
who, on examination, are found to have more or less incarceration of 
these hernias ; which emphasizes the importance of making a systematic 
physical examination in every case for abdominal hernia, and of not 
taking it for granted that the symptoms are caused by indigestion. 

(1) Congenital Form. — The congenital form is that variety in which 
the knot of intestine has made its way along a still patent funicular pro- 
cess. If it reaches into the scrotum it will be found completely to en- 
velop the testicle. 

(2) Funicular Form. — In the funicular form, the tunica vaginalis 
having become shut off' from the funicular process just above the testicle, 
the hernia comes down the patent process, but does not envelop the 
testicle as in the preceding variety. 

(3) Infantile Form. — Compared with the two forms just mentioned, 
the infantile or encysted form of hernia is quite rare, nor can it be diag- 
nosticated with certainty without an operation. In it the funicular pro- 
cess has closed above but not below, and the intestine encased in a pouch 
of peritoneum forces its way into the process and descends. 

Diagnosis. — The diagnosis between direct and iu direct hernia has little 
importance in childhood, as the inguinal canal is so short that the rings 
are practically at the same level. The condition which will be most 
readily confounded with hernia is hydrocele. Both give rise to an elastic 
tumor in the inguinal region and in the scrotum, and in fact resemble 
each other in many ways. Hydrocele is translucent by transmitted light ; 
hernia is opaque. Hydrocele is always dull on percussion ; hernia is 
usually resonant. If you can reduce them, hydrocele will go back slowly 
and noiselessly, hernia at the last quickly and with a gurgling sound. 
Hydrocele gives no impulse on coughing ; hernia usually does. Lastly, 
in feeling for the inguinal ring in hernia it is found to be filled with the 



DISEASES OF THE NEW-BORN. 305 

neck of the tumor; in hydrocele it is either empty or filled by a narrow 
stalk. 

Treatment. — Most of the hernige that will be met with in children are 
easily reducible, but we should remember that in attempting to get them 
back into the abdominal cavity we must use the greatest care, as nowhere 
can a little rough manipulation do more harm. If the hernia cannot be 
easily replaced, we should not think of leaving it where it is, simply be- 
cause it gives rise to no alarming symptoms on the part of the child. 
No infant is safe with an irreducible hernia, and the sooner such a case 
is placed in the hands of a surgeon the better. Although the treatment 
of inguinal hernia, whether by actual operation or by the application of 
the usual trusses, should be in surgical hands, yet one method of treating 
these hernise is so simple and safe that every medical man should know 
about it ; in fact, in our children's clinics in Boston it is much used for 
all children under a year and a half. This method is the application of a 
worsted truss made of a skein of yarn which is passed under the back. 
The separated loop is around the side where the hernia is, and the un- 
separated end of the skein is brought forward and passed through the loop 
in the groin and up on to the back where it is fastened. In this way a 
soft slip-knot is made which lies directly over the inguinal ring and makes 
an excellent truss. 

Femoral Hernia. — In femoral hernia the gut escapes from the pelvis 
under Poupart's ligament, and, making its way through the femoral 
canal, shows itself as a tumor directly under the saphenous opening. It 
can be diagnosticated at once from inguinal hernia by putting the finger 
on the spine of the pubes and noticing whether the origin of the tumor 
is to the outer or the inner side of that point. If outside, one is sure the 
hernia came through the femoral canal, no matter how far it may have 
extended up on to the abdomen. Femoral hernia is, however, extremely 
rare in young children, even in girls. In infancy the spine of the pubes, 
Poupart's ligament, and the anterior superior spine of the ilium are all 
much nearer together than in the adult. As a consequence, the femoral 
opening is so small and so well protected that it is usually impossible for 
the hernia to force its way through. 

Hydrocele. — Several anatomical varieties are met with in hydrocele, 
as in hernia. Thus, if the collection of fluid occupies a freely open 
funicular process, we have the congenital variety, and the fluid can easily 
be returned to the abdominal cavity by placing the child on its back and 
elevating the scrotum. This is true also of funicular hydrocele, in which 
the fluid occupies an open funicular process, but is bounded below at the 
point where the tunica vaginalis has become walled off, leaving the testi- 
cle in a separate compartment underneath. When the funicular process 
has become walled off from the abdomen, but is still in communication 
with the tunica vaginalis, there may be a collection of fluid, which is then 
known as an infantile hydrocele; in this form the fluid is irreducible. 

20 



306 PEDIATRICS. 

True hydrocele of the tunica vaginalis may be met with in children as well 
as in adults, but it is rare. 

Encysted Hydrocele of the Cord. — There is another form of hydrocele 
which often escapes recognition, but perhaps still oftener is diagnosticated 
as hernia and treated with a truss. This is the encysted hydrocele of the 
cord. If in the course of the spermatic cord a hard, rounded swelling 
appears, and the testicle is found in its proper position in the scrotum and 
the inguinal ring clear, one is very surely dealing with a hydrocele of this 
kind. Having made the diagnosis, it should be evacuated with a fine 
aspirating needle. About 4 c.c. (1 drachm) of clear straw-colored fluid 
is generally drawn off, and the tumor usually disappears. 

Encysted Hydrocele of the Canal of Nuck. — Analogous to hydrocele of 
the cord in boys is an accumulation of fluid in the canal of Nuck in 
girls. The appearance of the swelling is the same in both cases, and the 
treatment should be the same. 

Treatment. — The treatment of all forms of irreducible hydrocele is 
first by aseptic evacuation of the fluid with a fine canula and trocar, or 
by an aspirating needle. If this, after repeated trials, fails to effect a 
cure, extirpation of the sac is the only sure method, although the injec- 
tion of a weak solution of iodine is highly recommended by many au- 
thors. It is, however, dangerous in children, as the occasional connection 
of the hydrocele sac with the abdomen is not to be forgotten. Reducible 
forms of hydrocele are generally to be treated by a truss, in the same 
manner as hernise, to try to effect a closure of the neck of the canal. If 
this is successful they can then be treated in the ordinary way. The 
outlook, however, is poor, and such treatment is generally unsatisfactory. 

Undescended Testicle. — The testicle should descend into the scro- 
tum at about the eighth month of intra-uterine life. In certain cases it 
does not descend, and if the descent does not take place within the first 
few years of life its function is lost from atrophy. It is, therefore, im- 
portant in those cases in which the testicle descends and returns to the 
abdominal cavity to retain it in the scrotum by means of apparatus. 
Operation for this condition is not often successful. At times an unde- 
scended testicle is found in combination with an inguinal hernia. The 
following case of this kind came under my care about two years ago : 



A boy, four years old, was discovered to have an inguinal hernia. The testicle 
was also found at times to be absent on the side of the hernia. Sometimes the her- 
nia would descend and the testicle remain in the abdominal cavity, and again the testi- 
cle would come down with the hernia. It was exceedingly difficult to maintain the 
testicle in the scrotum, even when it was found to be there, as it would slip back with 
the greatest facility. Dr. Lovett finally succeeded in seeing the boy at a time when 
both the testicle and the hernia were down, and in reducing the hernia while the testi- 
cle was kept in the scrotum. A carefully adapted truss was then applied so as to pre- 
vent the testicle from returning to the abdominal cavity and the hernia from entering 
the scrotum. 



DISEASES OF THE NEW-BORN. 307 

Tumors of the Testis. — We may at birth find an enlargement of the 
testis due to sarcoma, teratoma, congenital syphilis, or carcinoma. The 
former is much the more common. 

Malformations about the Rectum. — At an early stage of develop- 
ment of the embryo the intestinal canal ends blindly, and afterwards by an 
invagination of the outside wall a communication is brought about and the 
stomodaeum formed. An analogous process of development goes on at the 
other end of the intestinal tube, and results in the formation of the rectum 
and anus. The hind-gut at first ends blindly, then as it descends it is met 
by an ascending dimple, and usually these two fuse and the protodceum is 
formed. 

As in the mouth a series of malformations may arise from a failure in 
the completion of this process, so in the anal region we may meet with a 
similar series. The rectum may have come into its normal relations and 
the anal depression have failed to form, or it may have gone the whole of 
the distance between the end of the intestine and the skin and yet the 
final step, the fusion of the membranes, have failed to take place. To both 
of these, and to any intermediate condition, the name of imperforate rectum 
is given. On the other hand, with the rectum and the anus fused we may, 
nevertheless, find a thin parchment-like membrane spread over the exter- 
nal orifice just where the skin and the mucous membrane join. This is 
called imperforate anus. 

Treatment. — When an infant is born the physician should carefully 
examine it, in order to determine whether it has any malformation. The 
most important malformations which it is necessary to recognize are those 
at the anus. Unless an infant has a passage of meconium soon after its 
birth, an examination should be made in the rectum with the finger, and 
if the anal opening is found to be closed, either just at the outlet or higher 
up, we must consider what is to be done to relieve this condition. If 
nothing but a web obstructs the anus, we can easily break it through with 
a director and then dilate the orifice with the finger. If there is more 
than the thinnest bulging membrane, a cutting operation will have to be 
done, and perhaps a severe one, so that the case should at once be placed 
in the hands of a surgeon. 

Occlusion of the Vagina. — Sometimes we find a thin gray velum ex- 
tending across the mouth of the vagina from just below the urethral open- 
ing to the posterior commissure and blocking up the vagina. It may be 
complete or partial. 

Treatment. — This condition should be dealt with while the infant is 
still young, as, if left until puberty, it will cause a retention of the menses, 
and, moreover, by that time will have become much thicker and perhaps 
quite vascular. It is easily broken through in the young child, and if a 
piece of carbolized cotton be put between the torn edges to prevent them 
from adhering, the malformation can be cured permanently. Atresia from 
inflammation of the labia is said to occur in rare instances. 



308 PEDIATRICS. 

Hypospadias. — The malformation known as hypospadias is the result 
of an arrest of development in the formation of the urethra and of the 
corpus spongiosum. The urethral groove should normally be converted 
into a canal by the growth and joining together of its sides. This process 
begins at the base and extends to the end of the penis. By an interrup- 
tion of this process the urethra may be brought to an end and open at any 
point between the peno-scrotal angle and the base of the glans. In the 
most common forms of hypospadias the glans alone is imperforate. 

Treatment. — The treatment is wholly by plastic operation, and it re- 
quires the most delicate surgery to obtain a good result in the face of the 
many serious obstacles that this malformation presents. 

Epispadias. — The malformation of epispadias, in which the urethral 
canal opens upon the dorsum of the penis, is still more difficult to deal 
with than is hypospadias. It is commonly associated with extroversion 
of the bladder, and is very rare. 

Treatment. — A partial plastic operation and the wearing of some form 
of urinal constitute about all that can be done for these cases. 

Congenital Obliteration of the Bile-Ducts. — One of the rarer forms 
of congenital malformations in new-born infants is represented by the ob- 
literation of the bile-ducts. The most extended work which has appeared 
in the literature of this subject is that of Dr. John Thompson, of Edin- 
burgh. 

Pathology. — There are a number of different morbid processes which 
have been supposed to produce this pathological lesion of the ducts. Each 
of these processes has in certain cases, in all probability, had much to do 
with causing the disease, but it is usually the combination of one or more 
of them which must be considered in determining its etiology. Thus, the 
results of intra-uterine peritonitis, by compressing the ducts, or by being 
a source of inflammation which has spread to the walls of the ducts, may 
finally cause their obliteration. A primary inflammation or lesion of the 
ducts themselves may produce this result, or it may arise from an actual 
arrest or defect of development. In this connection congenital syphilis 
should be referred to as in some cases producing lesions of the ducts, but 
this and other causes do not necessarily play an important part in the dis- 
ease. 

The complete discussion of the causes of congenital malformation of 
the bile-ducts would hardly have a place in a general work on clinical 
medicine, but it is sufficient to say that in the great majority of cases the 
evidence is in favor of defective development as being the chief cause. 
This malformation probably affects to a considerable extent the walls of 
the ducts, and, as Thompson has stated, it consists in the narrowing of 
their lumen. The interference which is thus caused to the outflow of bile 
gives rise to a catarrhal condition which finally blocks and obliterates the 
ducts, owing to the inflammatory process spreading to the walls of the 
ducts and the gall-bladder. This progressive inflammation goes on slowly 






DISEASES OF THE NEW-BORN. 309 

spreading, the local condition gradually becoming worse during many 
months if the patients live. The obliterated ducts or gall-bladder, or 
portions of them, may entirely disappear, not even leaving a distinct band 
of fibrous tissue to indicate their original position. The obliteration gen- 
erally becomes complete at a variable but early period of intra-uterine 
life ; occasionally it does not occur until after birth. The occurrence of 
peritonitis is probably in most cases secondary to the blocking of the 
ducts. 

When the lumen of the duct has become so narrowed that the bile 
does not pass freely into the intestine, a cirrhotic condition begins in the 
tissues of the liver, and as it progresses interferes with the functions of 
that organ. 

At the post-mortem examinations of these cases the liver usually is 
found to be much enlarged and its tissues to be increased in consistency ; 
it is of a dark-brown color, owing to the presence of numerous masses 
of inspissated bile in the smaller bile-ducts. In a large number of cases 
there is found a complete obliteration of some part or parts of the hepatic, 
common, or cystic ducts, or of the gall-bladder, while, with very few ex- 
ceptions, implication of the blood-vessels is conspicuously absent. 

In speaking of the explanation which may be given for the occurrence 
of the symptoms just mentioned, Thompson remarks that the reappear- 
ance of the disease in several members of the same family can be ex- 
plained only by the theory that a congenital defect of development is in 
these cases the cause of the malformation. The fact that the onset of 
the jaundice is not contemporaneous with the blocking of the bile-ducts y 
and usually begins several days after birth, he explains as the effect on 
the hepatic cells produced by the great changes in the hepatic circulation 
which occur in new-born infants. The presence of colored meconium in 
some cases and of only white discharges in others is due to the blocking 
of the ducts having occurred at different periods of intra-uterine life. 

When in combination with the colorless faecal discharges green 
material is passed during the progress of the disease, this occurrence is 
probably due to the chemical action on the contents of the intestine, pro- 
duced in various ways, one of which may arise if mercury has been 
administered. The tendency to spontaneous hemorrhages may be due to 
the occurrence of a condition of chronic blood-poisoning, since the arrest 
of the outflow of bile damages the liver to such an extent that its func- 
tions are interfered with and organic fluids of a poisonous nature may 
thus pass into the circulation. The enlargement of the spleen, the con- 
vulsions, and the vomiting are probably more or less connected with the 
same condition of blood-poisoning. The fact that the children live as 
long as they do, and usually do not become emaciated in the early days 
of life, is to be explained on the ground that the presence of bile in the 
intestine is not absolutely necessary for digestion. When the nutrition 
and general health begin to suffer, it is probably due to the interference 



310 PEDIATRICS. 

which the secondary changes in the tissues of the liver are causing with 
the more important functions of that organ. 

Symptoms. — The infants who are born with this disease are either 
icteric at first or become so within the first few weeks of life. They often 
appear otherwise healthy and well nourished. In some cases there is a 
discharge of normal meconium followed by colorless dejections. In other 
cases the fsecal movements are clay-colored from the very first and 
remain so. The urine is deeply stained with bile. The jaundice is of a 
dark-greenish tinge, lasting until death, which occurs from within a few 
weeks to eight months. Spontaneous hemorrhage from the umbilical 
cord commonly occurs within the first two weeks, and in other localities 
in those infants who survive this early period. The liver and spleen are 
increased in size. If the infants survive for some months they become 
more or less emaciated. Convulsions and vomiting are apt to occur, and 
death usually takes place from exhaustion or from some trifling inter- 
current disease. 

Treatment. — There is no known means by which we can counteract 
the results of this malformation. 

Congenital Obliteration of the Intestine. — I shall merely refer to a 
malformation which is represented by an obliteration of the intestine. 
Malformations of this kind may arise from constrictions of the parts 
affected by fibrous bands, probably the remains of peritoneal adhesions. 

Congenital Malformations of the CEsophagus and Stomach. — 
Congenital malformations of the oesophagus and stomach are rare, and 
are described, in connection with diseases of these parts, on page 274. 

Malformations of the Heart and the Blood- Vessels. — The various 
anomalies of the heart and blood-vessels are described on page 720. 

DISEASES OP THE EXTREMITIES. 

Fingers. — Various malformations of the extremities are met with in 
new-born infants, one of these is six instead of five fingers. 

Another malformation of this kind, called webbed fingers, is quite 
common. Surgical interference is indicated in both cases. 

Toes. — Infants are at times born with extra toes and webbed toes, and 
it becomes a surgical question to determine whether they shall be operated 
upon. This, of course, is a question of orthopaedics, and is one which 
we need not deal with except so far as to appreciate the importance of 
preparing the foot properly for future use. The greater freedom of move- 
ment required for the fingers, and the fact that the hand is always in sight, 
render surgical interference much more necessary in malformations of the 
hand than in those of the foot. 

Congenital hypertrophy of the feet and hands, and congenital deficiency 
of one or more extremities, may be spoken of in this connection, but are 
too rare to be more than referred to. These malformations have been 
thoroughly described by Thomas Annandale. 



DISEASES OF THE NEW-BORN. 311 

Club-Hand and Club-Foot. — Club-hand and club-foot are congenital 
malformations which may be due to an undeveloped condition of either 
the bones, the ligaments, or the muscles. In the more simple forms the 
extremity is pulled into the malposition by the action of contracted mus- 
cles and tendons, while in the severe forms the bony framework may be 
so misshapen that the separate segments are almost unrecognizable. 
Club-hand is often accompanied by absence of the radius. 

Treatment. — The treatment of this class of deformities is, of course, 
purely in the province of the orthopaedic surgeon. All that I wish to do 
in referring to them is to suggest how much may be accomplished by 
simple manipulations with the hand. The mother should be instructed 
to rub the foot and leg twice daily, and to make firm pressure against the 
shortened muscles by trying to bring the hand and foot into the normal 
position. I have seen slight cases cured by this simple means, and even 
moderately severe ones so much benefited that subsequent treatment with 
orthopaedic apparatus became much easier. 

Congenital Dislocation of the Hip. — Congenital dislocations of all 
the joints are sometimes found, the most frequent and most important 
being dislocation of the hip. This is now thought to be caused by a 
faulty development of the acetabulum and the head of the femur. 

Symptoms. — The symptoms are of a kind that readily escape notice 
during infancy, and are first seen when the child should begin to walk. 
It is then noticed, if he can hold himself on his feet at all, that the abdo- 
men is very prominent, the back arched, and the buttocks seemingly en- 
larged : at least this is the case if the deformity is bilateral, which is the 
form usually met with. On examining the joint we find that the trochan- 
ter is above Nelaton's line, but it can by traction on the leg be drawn 
down to its proper place without causing any discomfort to the child. If 
the deformity is unilateral, one leg will appear shorter than the other, and 
the child will walk with a rolling limp. This condition should be care- 
fully looked for when an infant at the age of fourteen or fifteen months 
has made no especial attempt to walk, or when on attempting to do so it 
..does not succeed. 

Treatment. — As operative treatment has not proved very successful in 
these cases and is not to be employed until the child is over three years 
old, the best method of treatment is by massage. If the disease is unilat- 
eral it should in addition to the massage be treated with a high shoe. 

Congenital Dislocation of the Knee. — Next in order of frequency to 
congenital dislocation of the hip, but rare in comparison, is a dislocation, 
or rather a partial dislocation, of the knee. In this condition the tibia is 
found riding forward upon the condyles of the femur, so that the knee- 
joint can readily be put into hyperextension and the toes made to point 
towards the forehead. 

Birth Paralysis. — Birth paralysis will be considered in connection 
with diseases of the nervous system. It may be present either in the 



312 PEDIATRICS. 

muscles of the face or in those of the extremities, and is due to pressure 
upon the nerves made by the forceps or by too great traction. 



GENERAL DISEASES. 

Asphyxia. — The earliest pathological condition which is brought to 
our notice at birth, and one which requires immediate treatment, is as- 
phyxia. This condition, which is a failure of the circulatory mechanism 
to assume its extra-uterine function of oxygenating the blood, endangers 
the life of the infant from carbonic acid poisoning. It may arise either 
from mechanical pressure, as from winding of the cord around the neck, 
from an incomplete expansion of the pulmonary alveoli, atelectasis, or 
from other causes connected with the imperfect oxygenation of the blood, 
of which we have very little knowledge. In any case the cause, if known, 
must be quickly removed. This class of cases belongs so directly to 
the province of obstetrics that it need hardly be more than mentioned. 
Prompt measures for performing artificial respiration, as by Crede's method,, 
and the stimulation of the pneumogastric nerve by the application of heat r 
cold, and electricity, should be borne in mind : they are well described in 
Dr. Edward Reynolds's work on practical midwifery. 

Acute Fatty Degeneration of the New-Born (BuhVs disease). — An 
affection which has been called acute fatty degeneration of the new-born 
was described by Buhl in 1861. It is not a disease of common occur- 
rence, and its etiology and pathology have not yet been satisfactorily de- 
termined. Runge, of Dorpat, has written more fully on this disease than 
any other author, and I am indebted to him for the careful description 
which he has made of the affection and the literature which he has col- 
lected concerning it. 

As the anatomical diagnosis can be made only by using the microscope, 
the disease has probably often been overlooked, and the cause of death 
ascribed on the one hand to inanition and on the other to such especial 
forms of hemorrhage in the new-born as omphalorrhagia and melaena. If 
the numerous causes of hemorrhage from the cord had been more care- 
fully examined anatomically, the disease would probably not have re- 
mained so long unknown. 

Etiology. — The etiology of acute fatty degeneration of the new-born 
is very obscure. The disease occurs in animals as well as in human beings, 
but the investigations made by different observers both on animals and on 
infants are so varied in their results that we cannot at present consider 
that we know much about the cause of the disease. It is significant, 
however, that Buhl in his classic description of the disease states emphati- 
cally that the vessels of the cord are not affected, so that if it is due to 
sepsis the sepsis must have occurred in intra-uterine life through the 
mouth, the intestinal canal, or the umbilicus, but without producing any 
change in the umbilical vessels. This can scarcely be considered proba- 



DISEASES OF THE NEW-BORN. 313 

ble. We know nothing concerning the etiology of this disease, not even 
whether it is of intra- or extra-uterine origin. 

Pathology. — The pathological conditions which represent the disease 
consist of a parenchymatous inflammation, followed by a fatty degenera- 
tion of the tissues of the heart, liver, and kidneys, and hemorrhages in 
the various organs. The post-mortem examination of infants dying of 
this disease, as a rule, shows the following changes. The cadaver is livid 
and usually icteric. Hemorrhages and oedema are often found in the 
skin. The umbilicus and the tissues surrounding it are at times stained 
with blood, but, as a rule, are otherwise normal. The umbilical vessels 
are in most cases normal. These hemorrhages are especially found in 
the dura and pia mater, in the pleura and pericardium, and in the con- 
nective tissue of the mediastinum : they also occur in the thymus gland, 
in the peritoneum, in the muscles, and in most of the mucous membranes. 
The brain is found to be soft, usually full of blood, and, if icterus is present^ 
is stained yellow. The lungs often show hemorrhagic infarction, and 
in the bronchi bloody mucus or pure blood. The alveolar epithelium 
is in a condition of fatty degeneration. The muscles of the heart are 
friable. In the early stages they are rigid and dark red, while in the 
later stages they become softer and paler. In almost all of them the pro- 
cess of fatty degeneration is found. In recent cases the tissues of the liver 
are blood-red, while in the later stages they are pale and icteric. The 
liver-cells contain fat-drops and granules of biliary coloring matter. The 
spleen is usually found to be enlarged, and its parenchyma is soft and 
almost fluid. Hemorrhages may be found in the walls of the stomach 
and intestine, and their cavities are often found to be filled with blood. 
Multiple hemorrhages are found in the parenchyma of the kidney. The 
cortex is swollen in the early stages, is filled with blood, and is pale and 
yellowish. The epithelium of the convoluted tubules shows marked fatty 
degeneration, and the canals are often filled with fatty degenerated mate- 
rial. The process of fatty degeneration does not in all cases affect all the 
organs. In some the changes may be absent or a parenchymatous con- 
dition may be present 

Symptoms. — The infants who are affected by this disease are usually 
born in a condition of extreme asphyxia without any apparent cause for 
it. Attempts at resuscitation are, as a rule, only partially successful, and 
at times not at all so, many of the cases dying at once. Diarrhoea is 
commonly present, and is often accompanied by blood from the rectum. 
There is sometimes vomiting of blood. Often, after the cord has separated T 
there may be a parenchymatous hemorrhage, which, although small in 
amount, is at times sufficient to cause death. There is usually a bluish 
color of the skin, which changes gradually to yellow or a mixture of yel- 
low and blue. Hemorrhages occur frequently in the skin, the conjunctivae, 
the mucous membranes of the mouth and nose, and sometimes the outer 
ear. Icterus may be present in these cases, and at times may become 



314 PEDIATRICS. 

intense. Sometimes oedema occurs, and without any noticeable rise of 
temperature there may be a rapid collapse, followed by death, commonly 
within the first fourteen days of life. These symptoms are not always so 
well marked as I have just described them. The external hemorrhages 
may not occur, and the cyanosis, slight at first, may rapidly increase and 
be followed by sudden death. This sometimes happens so quickly that 
we are reminded of the conditions which are met with in cases of death 
by violence. 

Diagnosis. — A definite diagnosis cannot be made without a careful 
microscopic examination. This disease must not be confounded with phos- 
phorus or arsenic poisoning, in which the organs undergo similar path- 
ological changes. The history of the case and a chemical examination 
of the organs will enable you to eliminate these other causes of fatty de- 
generation. The differential diagnosis between this disease and cases of 
sepsis in which hemorrhages and parenchymatous changes occur is very 
difficult. When the vessels of the cord are affected, we must in most 
cases consider the cause to be septic ; when the cases occur in groups, as 
is seen at times in hospitals or other places where a number of infants 
are gathered together, this same cause must be suspected ; also when 
putrefactive changes have progressed rapidly in the cadaver we should be 
inclined to regard the case as one of septic poisoning, as these changes, 
according to Hecker, do not occur in the specific disease called fatty 
degeneration. 

Fatty degeneration at times simulates so closely the appearances 
caused by death from suffocation that its presence becomes a question 
of great importance from a medico-legal stand-point. The cyanosis, the 
condition of the lungs, and the ecchymoses, also the absence macroscopi- 
cally of other organic changes, can easily suggest suffocation. For this 
reason in all cases of death among new-born children where there is a 
suspicion of asphyxia, a careful microscopic examination should be made 
of all the organs. 

Prognosis. — The prognosis in this disease is very unfavorable ; all 
the cases in which the symptoms are pronounced die. It is possible 
that the milder forms of the disease can recover, but as yet we do not 
know enough about this class of cases to state what proportion of them 
lives. 

Treatment. — From what has been said concerning this disease it will 
be readily understood that the treatment is usually unsuccessful. Stimu- 
lants should be used and the food carefully regulated. 

Infectious Hsemoglobinsemia of the New-born (infectious hcemo- 
globinuria ; WinkeTs disease). — Infectious haemoglobinaemia is an affec- 
tion which is met with in new-born infants usually in the early days 
of life, and, as a rule, arises as an endemic disease in hospitals. A 
specific micro-organism has not yet been discovered, yet the endemic 
character of the malady and the changes which are produced in the 



DISEASES OF THE NEW-BORX. 315 

blood warrant us in supposing that it is an infectious disease. Al- 
though it had been described at an earlier date, yet the most systematic 
description of it which had appeared up to the year 1879 was that by 
Winckel, who in that year reported twenty-three cases of an endemic 
affection observed by him at the Dresden Lying-in Hospital. The disease 
was characterized by extreme cyanosis, icterus, hemoglobinuria, somno- 
lence, rapid collapse, and the absence of fever. Although in many re- 
spects it resembled closely the acute fatty degeneration described on page 
312. yet it had such characteristic symptoms and conditions of its own 
that for the present it should be kept separate from that disease. I am in- 
debted to Runge for a description of this disease. An analysis of Winckel's 
cases shows that it usually begins on the fourth day of life, and that it 
may attack strong, well-developed infants. The course of the affection is 
very rapid, its average duration being about thirty-two hours. Twenty- 
five and a half per cent, of all the children born at the time when this 
epidemic occurred had the disease, and of these nineteen per cent. died. 

Etiology. — The etiology of this disease is obscure. Winckel had the 
organs carefully examined chemically for poisons, such as phosphorus, 
arsenic, and chlorate of potash, but with negative results. Examinations 
in regard to carbolic acid poisoning have also been made in these cases, 
with negative results. 

The resemblance of this disease to acute fatty degeneration of the 
new-born is very striking. Most of the symptoms are common to both 
diseases. Larger hemorrhages are also not uncommon in this disease, 
but are not so marked as in acute fatty degeneration. The striking points 
of difference are the presence of hemoglobinuria and the fact that large 
numbers are affected at the same time in infectious hemoglobinaemia, 
while these conditions have not been found to occur in acute fatty de- 
generation. In studying the literature of this disease we find a number 
of observations by different authors. Dr. W. S. Bigelow describes an 
epidemic at the Boston Lying-in Hospital in which the chief symptoms 
were a dark color of the skin resembling somewhat that produced by the 
administration of nitrate of silver, hemoglobinuria, diphtheritic deposits 
on certain of the mucous membranes, and dark brown faecal dejections. 
In this epidemic ten infants were attacked and eight died, the average du- 
ration of the disease being five days. In one of these cases phlebitis 
umbilicalis occurred. Similar cases have been reported by Parrot and 
Herz, in which the urine was brown and strongly tinged with blood, and 
the kidneys and liver showed the condition of fatty degeneration. 

Epstein, of Prague, mentions similar cases in which prominent features 
were the thickening of the blood, which made it impossible to get a drop 
to examine, and the dark brown-red color of the urine. Epstein thinks 
that this disease is a septic process which probably starts in the gastro- 
enteric tract. He believes that he can controvert the apparent absence 
of fever by the fact that in the diseases of new-born infants great and 



316 PEDIATRICS. 

sudden variations of temperature occur, and in consequence the tem- 
perature, for its record to be of value, should be taken very often. 
Whether this is so or not, the disease has certain peculiarities, pointing in 
some cases to an apparent relation with sepsis, and in others to acute 
fatty degeneration. The obscurity as to the etiology of the disease has 
been rendered still greater by the incomplete examinations which have 
been made of this class of cases, with the exception of those by Winckel 
and Birch-Hirschfeld. 

Pathology.- — A careful post-mortem examination of WinckePs cases 
showed that there was cyanosis of the external and internal organs. 
Except in one instance, no pathological condition of the vessels of the 
cord was described. The cortex of the kidney was found to be wider 
than normal, to be of a brownish color, and to present numerous minute 
hemorrhages. In some places the pyramids were entirely black-red in 
color, and in other places numerous black streaks were found which con- 
verged to the papillae. This color was caused by the filling of the straight 
tubules with granules of haemoglobin. Intact erythrocytes were never 
found. The bladder was found to contain greenish-brown urine. The 
spleen was strikingly enlarged and hard. Its length was about 7.5 cm. 
(3 inches), and its weight 25 grammes (f- ounce). It was black-red in 
color, and on section the surface was smooth. Microscopic examination 
showed a considerable accumulation of brownish coloring matter, partly 
free and partly in the pulp-cells. 

In addition to these appearances in special organs, minute hemor- 
rhages were found in nearly all the organs, but especially in the pleura, 
pericardium, endocardium, mucous membranes of the stomach and small 
intestine, and kidney : they were also found in the dura and pia mater 
and under the capsule of the liver. The lymph-follicles were swollen, 
especially Peyer's patches and the mesenteric lymph-glands. A micro- 
scopic examination showed fatty degeneration of many important organs, 
especially the liver, and at times of the muscles of the heart. The bac- 
teriological examinations were, as a rule, negative, especially as regards 
the tissues of the intestine. Clumps of bacteria were found only once in 
the liver and once in the kidney. 

Symptoms. — The first symptoms were generally restlessness and cyano- 
sis, not only of the face but also of the body and extremities, and especi- 
ally of the back. The color increased progressively until it became a deep 
blue. To this Avas added an icteric color, which when death did not 
occur within twenty-four hours became very marked. The respiration 
was rapid ; the pulse was not especially increased in rate. The rectal 
temperature never rose higher than 38.1° C. (100.6° F.). The skin 
generally felt cool. Vomiting and diarrhoea occurred in some cases. The 
most striking symptom was the appearance of the urine. It had a pale- 
brownish color, and was passed frequently, and often with considerable 
straining. An examination showed that the color was due not to bile,. 



DISEASES OF THE NEW-BORN. 317 

but to haemoglobin. In the sediment were found numerous epithelial 
cells from the walls of the kidney, granular casts with blood-corpuscles 
adherent to them, micrococci, masses of detritus, and urate of ammonia. 
A small quantity of albumin was present. Later in the disease con- 
vulsions occurred, followed rapidly by death. It was noticed that if the 
skin, where the cyanosis was most marked, was scratched and then pressed 
hard, a tenacious, almost black-brown fluid exuded. An examination of 
the blood showed a marked increase of leucocytes and numerous gran- 
ules. 

In other cases besides those of Winckel's in which the blood was ex- 
amined the condition was found to be one of haemQglobinaemia. The per- 
centage of haemoglobin was high, and free haemoglobin was found in the 
blood-serum, while the erythrocytes were greatly reduced in number, at 
times amounting to only 1,700,000 or even less. 

Treatment. — The treatment should be the administration of oxygen 
and stimulants, and forced feeding by means of a dropper where the 
infant is too weak to suck. 

Hemorrhage in Early Life. — Spontaneous hemorrhage occurring at 
some period during the early years of life is not uncommon. These 
hemorrhages may occur either in the skin or from some trifling traumatic 
lesion, or they may take place in various internal organs, and especially 
from the mucous membrane of the mouth and the gastro-enteric tract. 
A definite division of this class of cases has never been thoroughly made, 
so that the subject has always been somewhat involved in obscurity. The 
probability is that these spontaneous hemorrhages are simply symptomatic 
of different specific diseases, and that as our knowledge of these diseases 
increases we shall find it necessary to make a clear distinction between 
cases which now are spoken of under one head. The propriety of sepa- 
rating cases of spontaneous hemorrhage which occur in the early days 
and weeks of life from those which arise later has been shown by Town- 
send. He has by a series of observations corroborated the now generally 
accepted opinion that the hemorrhages which occur in the new-born 
should be separated from those met with in connection with the haemophilia 
of a later period of childhood and of adults. He has called this disease 
the hemorrhagic disease of the new-born. The hemorrhages which occur in 
new-born infants are so general in their distribution, and yet so uniform 
in their general symptoms, that they can well be classed under this one 
heading. These hemorrhages occurring in the early weeks of life run a 
definite course, and end in death or in complete recovery. The self- 
limited nature of this affection corresponds to what is seen in the acute 
infectious diseases, and suggests a relationship to them. The hemorrhage 
may arise from the gastro-enteric tract, from the mouth, the nose, or the 
umbilicus, also from the skin, and in the latter case may show itself in 
the form of ecchymoses. Again, it may occur in the form of hemorrhages 
in the abdominal cavity, the meninges of the brain, the pleura, the lung, 



318 PEDIATRICS. 

and the thymus gland. Townsend has collected fifty cases of this disease, 
and has tabulated the sources of the hemorrhage, as follows : 

Locality. Cases. 

Intestines 20 

Stomach 14 

Mouth 14 

Nose 12 

Umbilicus 18 

Ecchymosis in skin 21 

Scratch of skin 1 

Cephalhematoma . 3 

Meninges 4 

Abdominal cavity 2 

Pleural cavity . 1 

Lung 1 

Thymus gland 1 

From the gastro-enteric tract, nose, and umbilicus, accompanied by ecchy- 
mosis in the skin 3 

From the gastro-enteric tract alone 19 

From the umbilicus alone 3 

From ecchymosis in the skin alone 6 

The mortality in these cases was 62 per cent. The bleeding first 
showed itself in all but three within the first seven days of life, the ex- 
ceptions being on the eighth, ninth, and fourteenth days. The hemor- 
rhage in the majority of these cases began on the second or third day, 
thirteen starting on the second and sixteen on the third day, while only 
eight began on the fourth and two on the first day. One-half of the 
fatal cases lasted one day or less, and all the others died within a week, 
except one case, in which death took place from the effects of the hemor- 
rhage on the eighth day and several days after the bleeding had ceased. 
The cases that lived recovered within nine days, and two-thirds of them 
within five days. 

The cases of pseudo-menstruation which occur not uncommonly in 
the early days of life should not be included in the cases which are 
classed under the heading of hemorrhagic disease. The hemorrhagic 
disease is apparently infectious and is a general and not a local one, and 
is found more frequently in hospitals than in private practice. This fact 
is well exemplified by comparing the percentage of hemorrhagic cases 
which occurred among 7225 infants observed in the Boston Lying-in Hos- 
pital and its out-patient department. The percentage of the disease in 
the hospital itself was represented by 0.57, while 0.10 represented the pro- 
portion outside of the hospital. In Townsend's fifty cases the proportion 
of females to males was as 20 to 30. In four of Townsend's cases the 
hemorrhage took place in several other places as well as at the base of 
the cord, but the patients recovered and the cord separated, in one case 
in two days and in the other three in four days after the cessation of the 
disease, without a fresh hemorrhage occurring. 

In fourteen of these fifty cases the temperature was carefully observed, 



DISEASES OF THE NEW-BORN. 319 

and in all but two was found to be elevated at first from 38.3° C. (101° 
F.) to 39.5° C. (103.1° F.), and in one case to 41.1° C. (106° F.). After 
the cessation of the hemorrhages the temperature was normal, and often 
subnormal. 

To recapitulate : it would seem that we are warranted in considering 
the disease as one of a general nature, and infectious, for the following 
reasons. (1) It occurs usually in hospitals. (2) It is self-limited in its 
course, and, although a dangerous disease, may be completely recovered 
from in one or two weeks and never return. (3) The temperature is 
raised during the continuation of the chief symptoms, and becomes normal 
or subnormal when the hemorrhage has ceased. 

Ritter at the Prague Foundling Hospital has also noticed a great pre- 
ponderance of cases occurring in hospital deliveries over those which 
were met with outside of the hospitals. 

In connection with the hemorrhage which occurs in the gastro-enteric 
tract, the tar-color of the intestinal dejections, arising from the hemor- 
rhage taking place high up in the intestine, is noticeable. The resem- 
blance of the color of the dejections to that of meconium may cause the 
disease to be overlooked. A slightly pink tinge on the napkin around 
the dejection is often, however, seen, and where there is a doubt as to 
whether the stain is from blood or not, it can usually be determined by 
means of the microscope. When the corpuscles have become disinte- 
grated, as at times occurs, the haemin crystals may be recognized by means 
of a simple test which I shall speak of later. The post-mortem examina- 
tion which was made in nine of these cases throws no additional light 
upon the nature of the affection. The source of the hemorrhage was 
found, but in no case were there any gross lesions of the mucous mem- 
brane or the blood-vessels. In all these cases the infants looked very 
anaemic. In one case cultures were made by Professor Councilman from 
the blood, with negative results. We do not know what the cause of this 
disease is, but it is probable that in the great majority of cases it has an 
infectious origin. 

The cases which are commonly designated as melcena neonatorum 
should be classed under this heading of the hemorrhagic disease of the 
new-born. 

An interesting case of this disease was seen by me in consultation 
with Dr. Bush. 

A male infant apparently healthy at birth developed on the third day of its life 
ecchymoses on its head, groins, and one foot. There was also hemorrhage from the 
upper part of the intestine on the fifth and sixth day, the dejections being tar-colored 
from altered blood which simulated meconium. On the fifth day the child developed 
a marked paralysis of the left side of the face, and to a less degree of the left arm and 
leg, presumably from a meningeal hemorrhage. On the seventh day of the disease the 
hemorrhage had apparently ceased, as the paralysis was beginning to disappear. On 
the twelfth day the paralysis of the left arm and leg had improved : there was, how- 



320 PEDIATRICS. 

ever, still some paralysis on the left side of the face, but this did not continue to any 
great extent, and in the third and fourth weeks decided improvement took place in the 
child's condition, and there were no longer any evidences of hemorrhage nor any paral- 
ysis. The infant improved rapidly during its first year, and became healthy and strong. 
It learned to walk and talk rather later than usual, but at four years of age was in 
a normal condition both mentally and physically. 

I have met with a number of cases in which these hemorrhages oc- 
curred which varied greatly as to extent and persistence. The cases in 
which umbilical hemorrhage was present showed this same tendency to 
self-limitation, and could be distinguished from those which are classed 
under haemophilia. In fact, it is probable that most cases of umbilical 
hemorrhage are caused by infection and are not especially connected with 
haemophilia. 

The following case of umbilical hemorrhage in a male illustrates what 
has been said concerning the desirability of separating the hemorrhages 
taking place in the early days and weeks of infancy from those which 
occur later and in childhood. 

The parents of the infant were well and strong, and were Russian Poles. They had 
another child, eighteen months old, which was healthy. The mother had never had 
any miscarriages, and stated that her parents were healthy, as were also those of the 
father. The labor was a normal one, the child presenting in the first position, and 
nothing abnormal was noticed, except that the placental end of the cord continued to 
bleed quite freely notwithstanding the application of two ligatures. On the day follow- 
ing the delivery the mother and infant were both doing well ; the latter showed slight 
signs of icterus, but nursed well, and the former had plenty of good breast-milk. The 
infant continued to thrive, except that there was a slight hemorrhage around the inser- 
tion of the cord, which fell off on the eighth day. After the separation of the cord a 
slight hemorrhage from the umbilicus continued. On the thirteenth day the hemor- 
rhage increased, and became very extensive. The infant was then found to be de- 
cidedly jaundiced, though not deeply so. It was nursing well, but looked thin and puny. 
Nothing abnormal was discovered in the physical examination. Pale watery-looking 
blood was oozing from the umbilicus, and quite a large cloth had been soaked with the 
blood, giving evidence of a considerable hemorrhage. The umbilicus was plugged with 
small pieces of lint soaked in perchloride of iron, firmly compressed by a bandage, 
and alternate drop doses of fluid extract of ergot and tincture of chloride of iron were 
ordered to be given three times a day. 

On the fifteenth day the hemorrhage had somewhat abated, but it was not thought, 
advisable to remove the bandage ; the ergot was omitted, on account of nausea and 
vomiting. On the sixteenth day the infant was reported to have vomited and cried a 
great deal, and the plugs of lint had been forced out of the umbilicus, leaving a bleed- 
ing surface ; the umbilicus was then tamponed with Monsel's solution of subsulphate 
of iron ; the tincture of chloride of iron was omitted, as it caused vomiting. The 
hemorrhage then lessened and at times ceased. On the seventeenth day the older 
child pricked the infant's lip with a pin, and on the eighteenth day the lip was found 
to be still bleeding. The point of hemorrhage was cauterized with a stick of nitrate 
of silver. This controlled the flow of blood for about two hours, when it returned 
and continued. Compression of the lip finally stopped the bleeding on the twenty- 
fourth day. On the nineteenth day the hemorrhage had ceased at the umbilicus, and 
the child continued to nurse well. On the twenty-ninth day the bandage and lint were 



DISEASES OF THE NEW-BORN. 321 

removed from the umbilicus, and the abdomen was washed. There was no bleed- 
ing ; the child looked better, and there was not so much icterus. On the thirtieth 
day the infant was reported to be perfectly well. It continued to thrive from this time, 
with no recurrence of the hemorrhage. On the sixtieth day, although I advised that 
the operation should not be performed, the infant, in accordance with the Jewish cus- 
tom, was circumcised. I was present at the circumcision, to see if the hemorrhage 
would be easily arrested. The circumcision was performed without accident, and the 
hemorrhage was immediately arrested by a weak solution of iron. From this time 
there was no hemorrhage, and the child continued to be strong and well. 

This ".ase is an instance of the self-limitation of the hemorrhagic disease of the new- 
born, since, although it was a pronounced case of umbilical and general hemorrhage at 
the beginning of the infant's life, this tendency had ceased by the end of the second 
month, as was evidenced by the ready control of the hemorrhage after the circumcision. 

In another case which came under my notice the hemorrhage took place from the 
umbilicus in the early days of life at the time of the separation of the cord, and was 
completely uncontrolled even by ligatures passed around needles introduced through the 
skin of the abdomen on either side of the umbilicus. This case eventually recovered. 

In none of these cases has a tendency to bleeding developed in later life. 

At times we meet with what are apparently very mild cases of this 
disease. The following case was seen in consultation with Dr. George 
Haven. 

The infant, a girl, well developed, and weighing 3358 grammes (about 7 pounds 6 
ounces), was born at 12.45 a.m. Nothing abnormal was found on examining it, and 
it was perfectly quiet until fourteen hours after its birth, when it began to be very rest- 
less. This restlessness continued, and the temperature, which at birth was 38.6° C. 
(101.5° F.) in the rectum, began to rise, until at the end of twenty-four hours it had 
reached 39.4° C. (103° F.). When it was thirty-six hours old, minute hemorrhagic 
maculae were noticed, first on the back of its right hand and arm and then on the right 
side of its back. A few hours later a number of these maculae also appeared on the right 
side of the chest, near the arm. It nursed vigorously, and did not show any signs of 
weakness, but its respirations were at times quite irregular. From this time no new 
lesions of the skin appeared, and no hemorrhages from any other locality, the maculae 
gradually fading away in ten days. After the first day the temperature fell gradually, 
and on the fifth day was again normal. Whether there was any loss of weight during 
the first ten days of life was not known, as it was considered unwise in the infant's 
precarious condition to weigh it. 

The cord separated on the tenth day without hemorrhage, and subsequently no 
abnormal symptoms arose, and the infant continued to thrive during the whole period 
of its lactation. 

Treatment. — The treatment of hemorrhagic diseases of the new-born 
unfortunately is usually inefficient. Gelatin has recently been tried. It 
is especially indicated in hemorrhage from the stomach and intestines, and 
in these cases should be given by mouth. A one- or two-per-cent. solu- 
tion given frequently and in as large amounts as can be tolerated will 
sometimes arrest the hemorrhage. Commercial gelatin usually contains 
the bacillus of tetanus, and its use in subcutaneous injections is therefore 
accompanied by great risk. Solutions of from one-quarter to one-half 
grain of suprarenal extract given by mouth have been recommended. If 
given at all, the physiological effects should be carefully watched. Applied 

21 



322 PEDIATRICS. 

locally to accessible bleeding points, it is of undoubted value. Caustics, 
such as nitrate of silver and chromic acid, and astringents may be used 
for local applications. Careful feeding, the maintenance of bodily tem- 
perature, and stimulants in case of threatened collapse are important 
points in the management of all forms of hemorrhagic disease. 

Sclerema Neonatorum. — Sclerema neonatorum is a disease which 
occurs in the early days of life, and usually among those who are born 
in the midst of exceedingly poor hygienic surroundings and in cold 
weather. It is characterized by a hardening of the skin and the subcu- 
taneous cellular tissue and by a great reduction in the temperature. The 
tissues continue to grow cooler and harder until death, which occurs 
usually about the ninth day. It is a rare and exceedingly fatal disease. 

It should not be looked upon as a local disease of the skin, but as 
some obscure constitutional affection of the respiratory and circulatory 
systems, as shown by the shallow respirations and the diminished activity 
of the circulation. 

A number of cases of this disease have been reported in Europe, and 
several in this country, notably by Osier. Some investigators think that 
they have found characteristic changes in the skin. The observations of 
Northrup, however, who published the first report of a typical case of 
this kind in America, seem to show that there is no definite lesion of the 
skin. Northrup made a careful study of his case, and has plainly shown 
by sections of the skin compared with normal control specimens that the 
histology of the disease does not reveal any change which can be regarded 
as characteristic. This case embodied every feature of the typical scle- 
rema of the new-born. The infant was a foundling, born in a wretched, 
damp habitation, and was the weaker of twins. On the fifth day of its 
life the feet were found to be swollen, and soon began to give on palpa- 
tion a feeling of hardness like that of a board. This condition soon 
spread upward to the legs, thighs, hips, shoulders, arms, face, and scalp. 
The whole body felt as though it were half frozen. The temperature in 
the rectum was under 35° C. (95° F.). The infant died on the ninth day. 

Symptoms. — Soon after birth, spots of circumscribed hardness appear 
on the skin. These spots soon become diffuse, and the disease, starting, 
as it usually does, in the feet or the calves of the legs, passes up the 
thighs to the trunk. It may, however, first appear upon the face and 
upper extremities, though not commonly. The skin is waxy and glisten- 
ing, and is hard and cold ; the limbs become thick, stiff, and misshapen. 
The infant soon grows weak and somnolent, and refuses to take its food ; 
the breathing becomes rapid and superficial, the voice is weak and 
whimpering, and the pulse small and retarded. Towards the end of life 
a discharge of bloody serum from the mouth and nose often occurs, and 
death takes place seemingly from inanition. 

Treatment. — There is no treatment which has been especially success- 
ful in this disease, but the affection should be recognized at once, and 



DISEASES OF THE NEW-BORN. 323 

energetically treated with inunctions of hot oil and by massage and stimu- 
lants. 

CEdema Neonatorum. — (Edema neonatorum is a rare disease, which 
some authorities describe as distinct from sclerema neonatorum, the chief 
difference being that the skin pits on pressure and is not so hard as in the 
latter disease. The general symptoms of the two diseases resemble one 
another very closely. 

Icterus Neonatorum. — Icterus occurs from a number of causes in 
the new-born infant as symptomatic of disease. There is one form, how- 
ever, which is of so slight a grade and is characterized by so entire an 
absence of pathological symptoms that it is usually looked upon as repre- 
senting a physiological condition occurring in the transition from the intra- 
uterine to the extra-uterine ciculatory mechanism. It is to this condition 
that the name icterus neonatorum is given. It occurs in the first few 
days of life, and may not entirely disappear for several weeks. The most 
common time for it to begin is from the second to the third day, and, ac- 
cording to its intensity, the usual time of its continuation is from eight to 
fourteen days. It is not accompanied by any special symptoms. The 
conjunctivae are somewhat tinged with yellow in a certain number of 
cases, but it does not seem to affect the color of the faecal discharges or 
to appear in any quantity in the urine. 

Careful examinations of the blood in cases of icterus neonatorum fail 
to show any changes beyond what would be expected in the early transi- 
tional stage of blood development commonly found at this age. Plate II., 
facing page 80, represents a healthy male, ten days old, with the charac- 
teristic pigmentation of this disease. 

Its weight at birth was 3400 grammes (7 J pounds). At ten days it weighed 3200 
grammes (7 pounds). It was perfectly healthy at birth, and its skin was of the usual 
pink color which is seen in healthy new-born infants. On the fourth day of its life 
the skin began to show a yellow color, which soon became intensified, representing 
very well the picture of a physiological icterus neonatorum. The yellowish-brown 
color of the abdomen, and the slightly icteric color of the conjunctivae are to be noticed 
especially. The urine in this case was apparently normal, and the faecal discharges 
were tinged with the dark color of the meconium. In a week this yellow color will 
usually almost entirely disappear, and the skin will assume the natural pink color of 
a healthy infant in the first month of life. Later it will become whiter and more like 
the skin of the older child. 



As to the cause of icterus neonatorum, the investigations of Birch- 
Hirschfeld seem to be the most thorough and to offer the most rational 
explanation. This author says that it is difficult to avoid associating the 
icterus in some way with a disturbance of the hepatic circulation, owing 
to the transfer of its chief blood-supply from the umbilical vein. This is 
especially to be seen when we consider the very evident congestion and 
oedema of the liver which occur in cases in which the circulation through 



324 PEDIATRICS. 

the umbilical cord is interrupted before the respiratory movements, by 
their effect on the right side of the heart, afford an adequate compensation. 

This explanation of the cause of icterus neonatorum must not, how- 
ever, be regarded as conclusive ; for Cohnheim has in a number of autop- 
sies made on this class of cases failed to substantiate the conditions de- 
scribed by Birch-Hirschfeld. 

Treatment. — The ordinary bathing of the infant's skin is all that is 
necessary in these cases of icterus neonatorum, and I have never seen any 
indication for especial treatment of this condition beyond great care in 
establishing the equilibrium between the food and the digestion. 

Erythema Neonatorum. — At birth the skin is exceedingly sensitive 
to external influences, and in every case shows variations in color according 
to the degree of this sensitiveness, and to the greater or less amount of 
irritation, whether from temperature or from mechanical causes, to which 
it is exposed. 

The delicate layers of epithelium are commonly thrown off to such a 
degree as almost to represent a physiological desquamation, and it is often 
several weeks before the normal infantile condition of the skin is reached. 
In quite a number of cases this natural condition becomes intensified, and 
we find a uniform redness of the whole skin, which usually appears in 
the first two or three days of life. In a considerable number this hyper- 
semic condition of the skin gradually fades away in about a week, and is 
replaced by a normal pink color. In many other cases, however, the red 
color may be complicated by an icteric condition, or it may change with 
many intermediate shades of red and yellow into a pronounced icterus 
neonatorum. Plate II., facing page 80, represents a typical case of an 
uncomplicated erythema neonatorum. 

The infant, a female, weighed at birth 3000 grammes (6| pounds). It began to 
turn red when it was twenty hours old, and four hours later was of a dull but pro- 
nounced red color all over its face, head, thorax, and extremities. Its temperature 
and respirations were normal, and it seemed perfectly well. 

Symptoms. — There are usually no constitutional symptoms in these 
cases. When the hyperemia is very intense a slight desquamation is at 
times noticed. It is we'll, therefore, to study this rather peculiar red 
tinge of the skin in comparison with the redness of simple erythema, ec- 
zema, erysipelas, and scarlet fever, which, owing to the different degree 
of sensitiveness of the individual skin, may at times simulate erythema 
neonatorum as well as each other. The possibility of this error must be 
accepted, since these other diseases have been known to appear as early 
in life as in the above case, although it is unusual for them to do so. In 
one instance, at least, to my knowledge, a case of scarlet fever, which 
ultimately proved fatal to another child in the family, was considered by 
the attending physician, when he first saw it, to be a case of erythema 



DISEASES OF THE NEW-BORN. 325 

neonatorum in the second week of life, and yet eventually he admitted it 
to be the source of infection of the other members of the family and of 
the death of one of them. 

Treatment. — The application of a simple powder, such as is given 
below, with the use of water without soap on the skin, using enough 
only for cleanliness, until the redness has disappeared, is generally all the 
treatment that is necessary in these cases. 

Prescription 51. 

Metric. Apothecary. 

Gramma. 

R Pulv. zinci oxidi 30j R Pulv. zinci oxidi §i; 

Pulv. amvli trit 120| Pulv. amyli trit. ^ iv. 

M. M. 

Nsevus. — There are two forms of pathological disturbance in connec- 
tion with the blood-vessels of the skin which, appearing at birth, consti- 
tute a disease called nsevus. Both these forms can appear on the skin of 
any part of the infant, but its occurrence is especially unfortunate when 
it is located on the face. 

The first form is very superficial in its distribution, and is the one 
which is usually called "port-wine mark. 11 This form can in a number 
of cases be destroyed by the use of electricity. The second form, which 
is deep in its distribution, as a rule needs to be treated by the knife or by 
the Paquelin cautery. Cases of the superficial form of nsevus are quite 
common and vary greatly in degree. A frequent locality is between the 
eyes at the bridge of the nose, and another is on one of the eyelids. Often 
in these cases the disturbance disappears of itself after a few weeks or 
months and does not return. In other cases the lesion remains, often in- 
creases and continues, unless treated, through life. In the second form 
much can be clone by operative interference. This form also varies 
greatly in size and in the degree of the telangiectasis. In operating on 
these cases it should be remembered that at times the hemorrhage is 
great, and that the infants are liable to die from exhaustion. 



DIVISION VI. 

DISEASES OF NUTRITION. 



There are three diseases which so essentially belong to the early years 
of life, and so far as our knowledge of them goes are so obscure in their 
etiology, while presenting each in its own peculiar manifestations a clear 
picture of a vice of nutrition, that for the present we must classify them by 
themselves as dieases of nutrition. These diseases are rhachitis, osteoma- 
lacia, infantile scorbutus, and infantile atrophy. Of these, rhachitis and 
infantile atrophy are diseases of the first two years of life. Infantile scor- 
butus, while having its counterpart in the scorbutus of a later period, 
especially in its pathology and treatment, shows in its symptoms and 
course such a characteristic picture in the middle period of infancy that it 
may be considered at least as forming a special form of scorbutus. 

RHACHITIS (Rickets). 

Rhachitis is a disease closely connected with impaired nutrition. It 
occurs usually in infancy, rarely in early childhood, and appears at a time 
when the bones are in the process of development. It is chronic in its 
course, and although its chief lesions are in the bones, it involves all the 
tissues and organs of the body. Its chief characteristic is a local or gen- 
eral disturbance of the normal process of ossification, but exactly how the 
dietetic and hygienic causes which are supposed to produce these osseous 
changes accomplish their results is still unknown. The uniform and defi- 
nite changes in the bones in rhachitis lead us to consider it a disease of 
itself and one which, although connected with nutrition, is not merely a 
form of malnutrition. 

Etiology and Occurrence.-— There is no evidence that rhachitis is 
hereditary. Although the disease seldom begins before the sixth month 
or later than the third year, there is no doubt that it is met with at both 
an earlier and a later period, and cases have been reported in which the 
rhachitic rosary was seen as early as the fourth week after birth. The 
tendency of the disease to occur in the first two years of life is shown in 
the following collection of 1876 cases compiled by Guerin, Brunische, 
Rittershain, Ritsche, and Baginsky. 

326 



DISEASES OF NUTRITION. 327 

Cases. Per Cent. 

First year 710 37.8 

Second year 831 44.3 

Third year 232 12.4 

Fourth year 50 2. 7 

Fifth year 27 1.4 

Over five years 26 1.4 

1876 ~10CU) 

There does not seem to be any marked difference in the frequency 
with which boys and girls are affected by rhachitis. Out of 2595 cases 
reported by various authors, there were 1337 boys and 1258 girls. 

Such authors as Ziegler and Vierordt consider that foetal rhachitis is 
doubtful, but whatever the pathological point of view may be, a condition 
closely simulating rhachitis from a clinical stand-point exists occasion- 
ally during foetal life. At about the age of puberty also, in certain in- 
dividuals, the physical signs of rhachitis, with the exception of a lesser 
degree of epiphyseal enlargement, occur, and in these cases albuminuria is 
usually present. These cases are called the rhachitis of adolescence or 
late rhachitis. Certain races, such as the lower classes in Italy and Eng- 
land, are notably affected by rhachitis. The disease, on the contrary, in 
a marked form is not common among native-born Americans, nor is it 
as a rule, of so severe a type in America as in England ; and, except in 
colored children, or in Italians and Portuguese, great deformities are rare 
in America. Greeks and Gypsies seem to be almost exempt. The prev- 
alence of rhachitis among the colored population in Northern cities is most 
striking, and the disease is not so common among the negro population 
in the Southern States. The great predisposition to rhachitis which has 
been shown by the people in Southern Europe has never been accounted 
for. The most severe cases occur in cold, moist climates ; it is rare in 
sub-tropical, almost absent in tropical, regions, and almost unknown in the 
Arctic regions. It is seldom met with in China, Japan, Turkey, and the 
southern portions of Italy and Spain (Palm). Even in the regions where 
it is prevalent it is not common in the high altitudes. It is probable that 
a great number of cases occur very early in life, but are so mild in form 
that the rhachitic lesions do not become sufficiently marked for recog- 
nition until later. It is certainly much more common in its occurrence 
among all classes of life than was formerly supposed, and this is especially 
true of the population of large cities and towns. 

Out of 400 cases examined at the Infant's Hospital in a children's 
out-patient clinic by Morse, 80 per cent, showed distinct changes in the 
bones characteristic of rhachitis. This percentage is, however, undoubt- 
edly too low, as besides the fact that large numbers of cases of rhachitis 
do not present marked deformities of the head or extremities, and are, 
therefore, not always recognized, it was the case also that many infants 
only a few days old were included in the 400, and only those cases were 
called rhachitic in which changes in the bones were evident. 



328 PEDIATRICS. 

As a congenital disease it is probably associated with lack of proper 
intra-uterine development, corresponding to the rhachitis which is met 
with in cases of prolonged lactation. Like all diseases associated with 
impairment of nutrition, it is less likely to occur among breast-fed infants 
than among those who are deprived of their natural food, but if the breast- 
milk is deficient in fat and proteids the disease may develop, and it has 
been noted in New York (Holt) that among the Italians it is very common 
to see marked rhachitis in infants who are getting no food but that from 
the breast. In like manner it is more likely to develop in the latter part 
of the first year than in the earlier months, since in so many cases the 
breast-milk deteriorates in quality after the first six or seven months of 
lactation. The disease also seems to occur when the food is not properly 
adapted to the especial age, and the later children of large families are 
more apt to contract the disease than the earlier ones. According to the 
investigations of Konig, Forster, Gomp, and Besanez, it was found that 
there was not a deficiency of lime in the food taken by rhachitic children. 
It is most probable, however, that rhachitis is closely connected with some- 
thing which interferes with the assimilation of the lime-salts. In regard 
to the especial elements of the food which hold a prominent place in the 
production of the disease, it seems as though a low percentage of fat, es- 
pecially when combined with a low percentage of proteids, was conducive 
to the production of rhachitis. It is therefore very evident how the pro- 
prietary foods become a prominent factor in the production of the disease, 
for all of them contain a notably small amount of fat. Next to the food, 
the general hygiene is of the greatest importance, and the disease is es- 
pecially noticeable in the crowded tenement districts of large cities. The 
actual cause and nature of rhachitis is unknown. The disease is not 
hereditary, but is most apt to develop in children who have inherited a 
weak constitution. 

Rhachitis is a general disease, and there seems to be some change in 
the metabolism, possibly from the circulation of some substance, in conse- 
quence of which there are local changes in the metabolism with a lessened 
deposition of lime combined with a certain amount of resorption of bone. 
Whatever the other causes of rhachitis may be, it is evident that inter- 
ference with nutrition by improper food and lack of suitable hygienic sur- 
roundings play a prominent role in its production. 

An infectious cause for the disease, though still to be considered, has 
as yet in no way been proved. The theories of a lack of lime in the cir- 
culation, or the circulation of an acid, or a diminished alkalinity of the 
blood can be eliminated as causes. The growth of cartilage and of 
osteoid tissue may be the result of lack of lime, or may perhaps be pri- 
marily produced and may be an agent of bone change, but there is no 
proof of this. The vascular inflammatory theory of Kassowitz is not 
probable, and Oppenheimer's theory of malaria is without foundation. 

In addition to the causes of rhachitis, in which the etiology is some- 



DISEASES OF NUTRITION. 



329 



what obscure, many cases occur which evidently are secondary to and 
result from a number of diseases which affect the general nutrition of 
the infant. Thus, diseases of the gastro-enteric tract, when they are 
prolonged for some time, lead to the condition of rhachitis. We also 
meet with it in cases of syphilis in which the nutrition is much reduced ; 
but beyond this relation between syphilis and rhachitis, — namely, that 
rhachitis is secondary to syphilis, as it might be to any wasting disease, 
the two diseases are essentially distinct. It is to be noted in this con- 
nection that cases of infantile atrophy, no matter how much they are 
wasted, do not present the lesions of rhachitis, although in some cases we 
find the two conditions associated. We must also remember that the 
nutrition of all the tissues is profoundly affected, and that the equilibrium 
of the nervous system in rhachitis is very unstable. 

Pathology. — Bone Lesions. — The pathological lesions of rhachitis are 
represented chiefly in the bones, and occur during the period in which 
the normal processes of ossification are most active, — that is, during the 
first year and the first part of the second year of life. 

The normal growth of bone depends upon four conditions : (a) multi- 
plication of cartilaginous cells in definite lines, followed by (6) calcifica- 



Fig. 82. 



II. 




-z.p. 





i -Jfc 





-z.p. 



Z.P 1 




I. Normal bone : Z. P., zone of proliferation. II. Bone of a cretin : Z. P., zone of proliferation. 
III. Rhachitic bone : Z. P., zone of proliferation. 

tion of the intercellular spaces ; (c) the formation of medullary spaces by 
the penetration of blood-vessels, with subsequent absorption of tissue ; 
and, (d) finally, the concentric deposition of bone within the medullary 
spaces. The bones grow in length by the production of bone-tissue in 
the cartilage between the epiphysis and the diaphysis, and in thickness by 



330 PEDIATRICS. 

the growth of bone from the inner layers of the periosteum. At the 
same time the medullary canal is enlarged in proportion to the growth of 
the bone by the absorption of its inner layer. These processes progress 
in definite order and in clearly defined zones. 

In rhachitis the chief microscopic features are the changes which occur 
in the zones of growth and the asymmetrical character of the proliferative 
processes. The cartilaginous and sub-periosteal cell-growth which pro- 
duces ossification goes on with increased rapidity and in an irregular 
manner both between the epiphysis and the diaphysis and beneath the 
periosteum. If we examine microscopically the region between the epiph- 
ysis and the diaphysis, usually called the zone of proliferation, we find 
that the cartilaginous cells are not regularly arranged in rows around a 
definite zone in advance of the ring of ossification, as in normal tissue, 
but that there is an irregular heaping up of cartilaginous cells, sometimes 
in rows, sometimes not, covering an ill-defined irregular area. This zone 
of proliferation also, instead of being narrow and sharply defined, is quite 
lacking in uniformity. It presents a broad, reddish-gray appearance, with 
marked thickening and hyperemia. The medullary spaces are much 
more vascular than normal, and are so increased in area as to extend 
into the zone of calcification, and sometimes through it. The deposit 
of bone-tissue within these spaces is, however, either absent or very 
irregular, and is for the most part replaced by a soft, friable substance, 
consisting of a bone-tissue that is very lacking in lime-salts, with cells of 
various kinds embedded in a fibrillated ground-substance. This tissue is 
called " osteoid," and is similar to that formed by osteoblasts. 

In the region of ossification (ends of diaphysis and epiphysis) there 
is microscopically a pronounced increase of blood-vessels and cartilage- 
cells, with lengthening of cell columns, and disturbance of calcification 
of the intercellular substance. Calcification, if present, may be isolated 
in the region of the proliferating cartilaginous cells, or may be altogether 
absent over considerable areas. The sub-periosteal layer of cells which 
is normally thin and scarcely noticeable macroscopically, becomes hyper- 
aemic and thickened with an appearance similar to that of spleen-pulp. 
Beneath this periosteum is also to be found the " osteoid" tissue seen in 
the zones of proliferation. 

The medulla of the bone is more hyperaemic even than normal. Its 
tissue is rich in cells, and, like the foetal medulla, contains dilated vessels 
and fat. The intercellular substance may show mucoid degeneration or 
even be of fluid consistency. In such a condition it does not seem that 
lime is dissolved from the bone tissue by the blood, but it is the resorp- 
tion of such bone in toto that is the important factor in the process. 
Resorption at the age at which rhachitis occurs is normal. Pimmes, 
especially, believes that resorption in rhachitis is not increased. Muller 
and Virchow seem to hold the same views, while Kassowitz and Ziegler 
think it is increased. Clinically, certain extremely rapid cases of softening 



DISEASES OF NUTRITION. 



331 



seem to show increased resorption (Vierordt). Ordinarily, with a resorp- 
tion not greatly increased, the formation of fresh bone containing but 
little lime results in loss of strength. In the skull, in some places, ab- 
sorption predominates (occiput) ; in other cases accretion of osteoid tissues 
(frontal and parietal eminences). Deficient bone-growth simply deter- 
mines open fontanelles. In convalescence lime is deposited in the previous 
limeless osteoid tissue, and the result is a thick and heavy bone. In frac- 
tures at this period callus-formation is intense and excessive. 

An excessive proliferation of cells in the inner 
layers of the periosteum, the irregular calcifica- 
tion which occurs about them, and the absence of 
uniformity in the elaboration of the structure of 
the bone, produce an irregular, spongy bone-tissue 
instead of the compact lamellated tissue which is 
so necessary for the uniformity of the structure. 
The increased cell-growth between the epiphysis 
and the diaphysis produces the peculiar knobby 
swellings which are characteristic of rhachitis. 
At the same time the medullary cavity increases 
rapidly in size, and the inner layers of the bone 
become spongy. The result of these processes is 
to diminish the solidity of the bones so that they 
cannot resist the strain of the muscles or outside 
pressure. After a time the rhachitic process may 
stop and the bones may assume a more normal 
character. The porous bone-tissue becomes com- 
pact, and even unnaturally dense, so that in later 
childhood the rhachitic bone is unusually hard, 
like ivory, a condition noticed by those who have 
to operate on these bones. 

Fig. 82, I., represents a section of a normal 
bone taken from an infant, and shows the normal 
zone of proliferation (Z. P.) between the epiphysis 
and the diaphysis. 

Fig. 82, III., represents a section of a rhachitic 
bone, and shows the broad, irregular, and abnor- 
mal zone of proliferation (Z. P.) just described. 

Fig. 83 represents a section of a rhachitic bone, 
illustrating the great enlargement of cartilage at the epiphysis, with the 
irregular foci of calcification. The diaphysis of the bone shows perios- 
teal thickening to such an extent that it encroaches on the medullary 
cavity, which is much diminished. 

Visceral Lesions; Spleen. — The investigations made by Sasuchin 
(Jahrb. fur Kinderhl., March 13, 1900) have shown that in cases of rha- 
chitis which come to autopsy the spleen is invariably enlarged, with the 




Spindle-shaped rhachitic 
bone. 



332 PEDIATRICS. 

exception of the cases of clearly pronounced general atrophy, in which 
the spleen is of normal size and weight or below normal. A second 
marked characteristic is the more or less significant thickening of the 
capsule and the increase in the consistency of the organ. The third 
peculiarity of the rhachitic spleen is the anaemia of the organ and the 
diminution in the number of Malpighian bodies, which in children are 
otherwise well developed, but in these conditions are smooth and hardly 
perceptible. On section, the spleen has a blood-red color, the trabecular 
are clearly marked by interlacing threads, and on drawing the knife over 
the cut surface there remains upon the edge blood and pulp-tissue. The 
characteristics described hold true in all cases of rhachitis, and, in gen- 
eral, indicate approximately the intensity of the changes in the bones. 

The microscopic appearances are those of an interstitial splenitis. 
Whether the inflammatory appearances are directly dependent upon the 
rhachitis or are due to the complicating diseases which caused the death 
of the patient has not been definitely determined. The uniform appear- 
ances in all the cases examined by Sasuchin, irrespective of the cause of 
death, seem to give weight to the opinion that the lesions are directly 
connected with the rhachitis. 

Symptoms. — Constitutional. — The symptoms of rhachitis are those of 
a slowly developing constitutional disease. The early symptoms are the 
same as may occur in a number of diseases in which the nutrition is 
affected. The most common early symptoms are restlessness at night, 
profuse sweating, especially of the head, when asleep, and constipation 
alternating at times with diarrhoea. The appetite is impaired and ca- 
pricious ; the infants are fretful, the abdomen becomes prominent, and 
although they often grow fat they are anaemic and their muscles are soft. 
The increase in weight depends mostly on an increase in fat, the normal 
relative proportion between fat and muscle being altered. The infants do 
not learn to walk as early as they should ; their fontanelles do not close 
at the usual time ; dentition is delayed and irregular, and soft areas ap- 
pear in the cranial bones, especially in the occiput. 

At this stage the characteristic tenderness of the body may occur, 
but many cases never present this symptom. This is usually due to a 
periosteal tenderness at the insertions of the muscles, and is sometimes 
confined to the bones. It is manifested only on trifling pressure, while 
at other times the muscles are tender and the gentlest effort to lift the 
child may cause him to shriek with pain. It must, however, be remem- 
bered that pain in rhachitis may be connected with an early manifesta- 
tion of scorbutus, which is not an uncommon complication of rhachitis. 
The so-called paralysis of rhachitis, which is an accompaniment of this 
stage, and, as a rule, precedes any marked osseous change, is generally 
brought to notice by the child's inability or disinclination to walk or to 
stand. At other times it may be more severe and take the form of ina- 
bility to use the arms as well as the legs. There may be a slight and 



DISEASES OF NUTRITION. 333 

irregular heightening of the temperature apart from any complications 
which can be detected. 

Convulsions may occur, especially when there is a tendency to cranio- 
tabes. In certain cases these symptoms are all so acute that some writers 
would make them a separate class under the head of acute rhachitis, but 
the anatomical lesions and the symptoms are the same, except for their 
greater severity, and would seem to belong clearly enough to the same 
group as the less pronounced cases. There has also been much dis- 
cussion as to whether a form of acute rhachitis exists apart from the dis- 
ease scorbutus. But cases presenting the symptoms to be described under 
the heading of scorbutus should not be considered necessarily as acute 
forms of rhachitis on account of the severity of the symptoms, but should 
be classed as scorbutus supervening on rhachitis. The later and more 
characteristic symptoms of the disease soon appear and are represented 
chiefly in the osseous system. The facial expression is usually intelligent. 

After these general premonitory symptoms have continued for some 
time the characteristic changes in the osseous system become prominent 
and are found in those parts of the bones which are in the most active 
stage of development. In the early days of extra-uterine life the skull 
undergoes the most marked changes. 

Head. — The typical head of rhachitis has a high, square, prow- 
shaped forehead, with a decided prominence of the lateral parts of the 
frontal bones (frontal eminences), and sometimes there are also eminences 
on the parietal bones. (Fig. 86, page 337.) The normal thickness of the 
bones is increased by means of a large amount of new periosteal soft 
growth between the periosteum and the bones. The head is somewhat 
lengthened beyond the normal shape, and is usually larger in circumfer- 
ence than normal. The posterior fontanelle may remain open for a 
month, and the anterior fontanelle remains widely open, and may not 
ossify until the third year, or even later. The sutures also remain open 
longer than normal, and in such cases may result in leaving a depression 
in the course of the sagittal suture. Sometimes, however, a prominence 
is found instead of a depression. 

The square, lengthened, rhachitic head is shown in Fig. 86, page 337, 
and in Fig. 87, opposite page 342. Flattening of the back and top of 
the head and asymmetry of the head may result from softening of the 
bones. The normal shape is usually regained when the disease is cured. 
The bones may be soft, porous, and hyperaemic, while at their edges 
there may be rough bony projections beneath the periosteum. 

The name craniotabes is applied to an abnormal thinness of portions of 
the parietal and occipital bones, which are filled only with a fibrous mem- 
brane, and which yield to gentle pressure and give a sensation of crack- 
ling parchment. Hyperemia of the brain and meninges, of course, may 
be an accompaniment of any affection of the skull so severe as this. With 
this hyperemia comes the likelihood of hydrocephalus, either external or 



334 PEDIATRICS. 

internal, and the accompanying cerebral changes, so that hydrocephalus 
becomes a complication which is not very rare. This condition of the 
bone may be only temporary, and the areas of thickening are often ab- 
sorbed ; but if there is much deposit under the periosteum it will some- 
times remain, and where calcification takes place quickly the thickened 
areas of the bone will remain unabsorbed throughout life. At times the 
jaw-bones are affected ; the upper jaw is then found to spread behind, 
and to be pointed in front, while the lower jaw is flat in front and bent in 
at the sides, making an angle at the site of the canine teeth. 

Thorax. — The rhachitic thorax is narrow and is compressed laterally, 
— that is, there is a tendency to a flattening of the sides of the chest and 
to an increase of the antero-posterior diameter. The forces which pro- 
duce deformities of the thorax are dependent on the muscular action on 
the soft bones by pulling, atmospheric pressure from without, and the 
pressure exerted on the bony structures by growing organs. 

A transverse depression may also occur, starting at the junction of the 
ensiform cartilage to the sternum, extending laterally on the thorax^ and 
corresponding to the insertion of the diaphragm. This is called Harri- 
son's groove. The diaphragm, by its strong muscular action along the 
line of its insertion, may also cause a furrow in the lower part of the 
chest. The lower ribs may also be elevated by the underlying distention 
caused by the prominent abdomen and the liver, which is always, even 
in normal cases, large in proportion to the other organs. Softening of 
the ribs is said to occur (Vierorclt) after the changes in the skull and 
before the changes in the extremities. In a typical rhachitic thorax the 
clavicles are shorter and more curved than normal, and the clavicular 
deformities may be unilateral, as seen in Fig. 87, I. and II., facing page 
342. Fractures of the clavicles in rhachitis are not uncommon on the 
forward curve, and may possibly occur when the infant is being dressed. 

When there is unusual lateral compression and narrowing of the 
thorax, the sternum is made to project forward, and this is called pigeon- 
breast, or pectus carinatum. The weakest part of the thorax is at the 
junction of the cartilages and ribs, and the sternum is thus naturally 
pushed forward. In another series of cases, in which the ribs are pushed 
together laterally and the sternum depressed, as where there is inter- 
ference with the entrance of air into the lungs by adenoid growths and 
enlarged tonsils, the condition of funnel chest is produced, as seen in Fig. 
77, page 297. Again, there may be greater compression on one side 
than on the other, with a resulting prominence or depression on one side 
of the sternum. 

The costal cartilages are frequently enlarged at their junction with the 
ribs, and can be felt and often seen as a line of rounded prominences. 
These prominences are called the rhachitic rosary, and, though most com- 
monly occurring in the latter part of the first year, have also been met 
with in the early weeks of life. The rhachitic rosary, according to 



DISEASES OF NUTRITION. 



335 



Morse's observations on four hundred cases at the Infants 1 Hospital, is 
the earliest of the physical signs of rhachitis to develop, and is the most 



Fig. 84. 




Inner surface of sternum, with cartilages and portions of ribs attached, showing rhachitic rosary. 

common abnormality in rhachitis. It does not occur in normal chil- 
dren, and its presence justifies the diagnosis of rhachitis. The rosary 



Female, 3 years old. 



is sometimes present only on the internal surface of the ribs, as seen in 
Fig. 84, which represents a case in which the rhachitic rosary could not 



336 PEDIATRICS. 

be detected on the outer surface. As the pathological process is more 
pronounced in the lower ribs, especially the lower five, than the upper, 
the rosary is more distinct in the lower ribs. 

Spine. — Deformity of the spine is quite constant in rhachitis and results 
mostly from muscular weakness, but the vertebrae may be affected by the 
rhachitic process, and in cases of recovery may be found thickened. The 
most common deformity is kyphosis, which consists of a gradual bowing 
backward in the dorsal and lumbar regions, as seen in Fig. 85. 

The prominence of these vertebral spines is often quite sharp, and sim- 
ulates Pott's disease, but the rhachitic spine should be flexible to passive 
manipulation. In certain cases, however, it is rigid. Scoliosis (lateral 
curvature) and lordosis (forward curvature) are common deformities oc- 
curring in rhachitis. 

Extremities. — Deformities of the long bones may arise in the epiphy- 
ses and in the shafts : the former show enlargement, the latter bending. 
Enlargement of the epiphyses appears especially at the wrists and at the 
anterior ends of the ribs ; enlargement of the lower end of the radius and 
ulna is practically universal, whereas the enlargement of the lower end 
of the tibia and fibula occurred in four hundred out of a series of one 
thousand cases. The increase of the epiphyses at the wrists is greater 
than elsewhere. These enlargements do not involve the joints. In the 
deep-seated epiphyses, like the hip and the shoulder, the changes are not 
noticed so readily. The proliferating layer between the epiphyses and 
the bone may become so thick and softened that consequent deformity 
and separation of the epiphyses may occur, but such an event is uncom- 
mon. When fractures occur they are on the concave side of the bone. 
In rhachitis of the extremities the curve of the forearm may be due to 
the pull of the muscles, and there may be a special bend of the radius 
about the ulna, probably secondary to the antero-posterior curve. It 
prevents full supination. The humerus rarely bends. Fractures are not 
rare. In the acute forms of rhachitis the legs rotate outward in bed. 
Any considerable increase in the ankle epiphysis is rare. The curve 
of the femur is forward or forward anteriorly, so that in the latter case 
there may be no curve on the posterior surface. Fractures may occur 
with excessive callus. In the lower leg fracture takes place most often 
with anterior bow-legs, and the resulting callus is less than in the thigh. 
Fractures of the long bones, however, are uncommon, but their arrested 
development may cause permanent shortening. Bowing of the legs, 
knock-knee, and flat-foot are all very common symptoms of rhachitis. 
Coxa vara may be present. Localized rhachitis, as of the legs, is pos- 
sible and quite frequently met with in children with no symptoms of 
general rhachitis. It is not unusual to find hydrocephalus combined with 
rhachitis. 

Signs of previous rhachitis are suggested by a caput quadratum with 
a thick skull, irregularity of the teeth, eversion of the lower edges of the 



PLATE V. A. 

Khachitis. Age, 3 years. The centres of ossification of the epiphyses are relatively 
smaller than normal as compared with the diaphysis. The broadening is shown to take 
place in the bone of the diaphyses as well as in the cartilage of the epiphyses. The second- 
ary distortions of the bones are shown. A, deposit of cortical bone on concave side of 
diaphysis at the point of yielding to the crushing strain ; B, broadening of the epiphyseal 
line ; C, showing smooth surface of the centre of ossification towards the joint ; D, irregu- 
lar edges of the epiphyseal line ; E, spaces of poorly calcified bone in the spongy tissue at 
ends of diaphysis. 



PLATE V. B. 



Hereditary syphilis in a boy 8 years old. A, B, C, I), E, represent thickening of 
periosteal bone of the tibiae and fibulae in the order of the different stages of development. 



PLATE V. A. 




PLATE V B 




DISEASES OF NUTRITION. 337 

thorax, pigeon-breast, pelvic deformity, deformities of the clavicles and ex- 
tremities, and thickened epiphyses, which may persist, as thickened epiphy- 
ses in general are slow in disappearing and outlast the active process. 

- The existence of flat-foot in children over two years old should lead to 
an examination for knock-knee. The combination of these two conditions 
will in most cases be found to be dependent upon present or previously 
existing rhachitis. 

Muscles. — There is a weak and relaxed condition of the muscles, but 
microscopically the muscles are only pale and their fibres infiltrated with 
fat, although in some cases there may be atrophy from disuse. 

Nervous System. — The nervous system is in an exceedingly unstable 
and sensitive condition. Convulsions are quite common, especially in 
connection with craniotabes. The condition of spasm of the glottis 
(laryngospasmus), although it may occur in other diseases, is especially 
characteristic of rhachitis. The infants hold their breath, grow cyanotic, 
are seemingly unconscious, fall back entirely limp, and after a few min- 
utes recover. Tetany at times is met with as a complication. 

Lungs. — Owing to deformities of the thoracic walls there is a tendency 
to atelectasis of portions of the lung from pressure. There is also a great 
tendency to bronchitis and to broncho-pneumonia. 

Heart. — The heart often shows signs of mechanical irritation, repre- 
sented by irregularity and caused by deformities of the thorax. 

Fig. 86. 



.^waK 




Male, 3 years old. Rhachitis, with enlarged spleen. 

Blood. — Unless rhachitis is accompanied by a secondary anaemia, the 
blood is practically normal, and presents no other characteristic changes. 
Hock and Schlesinger found that if the secondary anaemia was moderate 
in intensity, and diarrhoea and vomiting occurred, it simply made the 
anaemia more acute. The majority of the leucocytes were found to be 
mononuclear and about the size of the erythrocytes. There is a mod- 
erate permanent leucocytosis in most of these cases, and at times the 
mononuclear leucocytes seem to be the most numerous form. 

Spleen. — In some cases the spleen is found to be enlarged, but it is 
rarely very large. 

22 



338 PEDIATRICS. 

The following case, Fig. 86, p. 337, is interesting as an illustration 
of rhachitis with a secondary anaemia of high grade, accompanied by 
enlargement of the spleen. 

The child was three years old, and was fairly well nourished. It had, however, 
enlarged epiphyses, a rachitic rosary, the square rhachitic head, and marked bowing 
of the legs. On physical examination no indication of enlargement of the liver or 
glands was found. The spleen was very much enlarged, and the position of its out- 
line and its notch is indicated in black. The blood examination showed a severe 
secondary anaemia, but no evidence of a leucaemia. 

Liver. — The liver often shows fatty infiltration, and is at times en- 
larged but less frequently than the spleen. A distinction must be made 
in these cases between an enlarged liver and a depressed liver, caused by 
rhachitic compression of the thorax and narrowing, or from relaxation 
of the natural ligamentous supports as a result of the weakness from the 
general inanition which affects all the tissues of the body. 

Lymph-nodes. — The lymph-nodes are very frequently found to be 
enlarged from simple hyperplasia. 

Stomach and Intestine. — There is usually, though not necessarily, 
functional disturbance of digestion ; also a subacute catarrhal condition 
and a tendency to gastric dilatation. The symptoms vary very much and 
diarrhoea and constipation alternate. Marfan thinks that the intestine is 
elongated in rhachitis. The distended abdomen results from weakness of 
the muscles of the abdominal wall and of the intestine, and a resulting 
umbilical hernia is quite common. In like manner atonic constipation is 
common. 

Diagnosis. — The diagnosis of rhachitis cannot be made by the pre- 
monitory symptoms, as the disease is so often the result of impaired 
nutrition arising from many causes, that it is difficult to determine when 
the rhachitic symptoms begin. The differential diagnosis has to be made 
from a number of diseases in which the general nutrition of the child is 
profoundly disturbed, these diseases being especially represented by func- 
tional disorders connected with the gastro-enteric tract. When the patho- 
genic changes in the bones have progressed sufficiently for physical detec- 
tion, and the disease is fully developed, the diagnosis is not difficult. In 
its early stages, therefore, the manifestations of rhachitis may be so slight 
that the diagnosis must often be held in abeyance. 

The differential diagnosis of rhachitis is to be made from scorbutus, 
rheumatism, osteomalacia, osteomyelitis, syphilis, paralysis of ceutral ori- 
gin, Pott's disease, and from the disability to use the limbs, due to simple 
weakness in infants who are not rhachitic. 

Scorbutus is eliminated in the diagnosis by the presence of the various 
osseous lesions which have just been described as symptoms of rhachitis 
and by the absence of the characteristic features of scorbutus, represented 
by tenderness and swelling just above the joints, without much fever, 
sub-periosteal hemorrhages, and stomatitis ulcerosa. 



DISEASES OF NUTRITION. 339 

Rheumatism in its articular form would present such marked symp- 
toms of acute tenderness, swelling, and pain in the joints, combined 
with a heightened temperature, that it could easily be distinguished 
from the general tenderness of the bones without much fever, together 
with the subacute or chronic course and the characteristic enlargement 
of the epiphyses in rhachitis. 

Osteomyelitis. — The clinical symptoms of an acute infectious disease, 
with sudden onset, and represented by severe constitutional disturbance, 
heightened temperature, pain, localized tenderness, and rapid exhaustion, 
serve to distinguish osteomyelitis from the slow development and slight 
amount of fever met with in rhachitis. In osteomyelitis, moreover, vari- 
ous foci of infection will appear in one or more bones with tenderness at 
these points and a tendency to suppuration which is not met with in 
rhachitis. 

Osteomalacia. — In very rare cases osteomalacia occurs in children, but 
it can seldom be differentiated from rhachitis during life. 

Hereditary Syphilis. — The diagnosis of rhachitis from hereditary syph- 
ilis is, as a rule, not difficult. Syphilis and rhachitis have no direct con- 
nection with each other, but are both chronic constitutional diseases, and 
it is possible to have both diseases occur in the same individual. While 
in rhachitis the enlargement of the long bones is limited to the epiphyses, 
in syphilis it is not so limited, but involves the ends of the diaphyses. 
This enlargement is often accompanied by a condition which closely simu- 
lates a callus, and there is a distinct tendency to fracture in syphilis 
rather than to the bending which is common in rhachitis. The notched 
teeth and the craniotabes may occur in both diseases, while the lesions of 
the mouth and lips described on page 527, and the lesions of the skin on 
page 525, are distinctive of syphilis. 

Cerebral Paralysis and Poliomyelitis. — In certain cases of rhachitis, es- 
pecially in the earlier stages, the so-called paralysis of rhachitis occurs, 
and must be distinguished from paralysis of central origin, especially from 
poliomyelitis of the cord. The differential diagnosis must be made by 
the absence of the symptoms described under cerebral paralysis and polio- 
myelitis described. on pages 950 and 958, and by an examination of the 
child in a recumbent posture, which in rhachitis will show that the muscu- 
lar movements are but little impaired, that the apparent inability to move 
the limbs and the disinclination to walk are caused by tenderness of the 
bones and muscular weakness, that the electrical reaction is normal, and 
that the reflexes are not affected. This pseudo-paralysis is certain to pass 
off if the child lives. Cases of rhachitis which do not walk until late, on 
account either of muscular weakness or of tenderness, may resemble 
cases of organic nervous disease with true paralysis. The diagnosis must 
rest on the presence of the general signs of these nervous diseases. 

Pott's Disease. — When rhachitis causes kyphosis of the spine it may 
simulate Pott's disease very closely. A prominence may be present at the 



340 PEDIATRICS. 

dorso-lumbar junction, which is a frequent seat of the deformity in Pott's 
disease, and which, involving several vertebras, may or may not be oblit- 
erated when the child lies on its face and is lifted by its feet from the 
table. The spine is held rigidly in severe cases, just as in Pott's disease, 
and the deformity may be angular rather than the usual gradual curve. 
The co-existence of enlarged epiphyses and other rhachitic conditions 
makes it very probable that the affection is rhachitic ; but both diseases 
may coexist. 

In general, the age of the child, under eighteen months, the absence 
of much pain, and the existence of other signs establish the diagnosis of 
rhachitis. Rhachitis is, moreover, in children under two, much more 
common than Pott's disease. In doubtful cases the diagnosis can be 
made only after several examinations and a period of two or three weeks 
of recumbency, under which conditions the rhachitic spine becomes 
somewhat more flexible. In doubtful cases time alone will establish the 
diagnosis. 

Weakness. — In certain infants who are not rhachitic the power of 
walking is lost for variable periods, and is due to weakness following any 
disease, whether acute or chronic, which for a time may interfere with 
the infant's vitality. This condition is difficult to distinguish from 
rhachitis, but must be differentiated by the absence of other symptoms 
of rhachitis. Delay in learning to walk should lead us to carefully ex- 
amine for other symptoms of rhachitis, as it is quite often one of the 
manifestations of this disease. An open fontanelle after the nineteenth or 
twentieth month suggests rhachitis, and delayed dentition is also signifi- 
cant. If there are no teeth at the ninth or tenth month, the infant 
should be carefully examined for rhachitis ; at one year absence of teeth 
almost always indicates the disease. Finally, the rhachitic attitude of an 
infant with well-marked rhachitis is characteristic, and is shown in Fig. 87, 
facing page 342. 

The infant stands with its thighs flexed, knees bent, back arched, 
shoulders thrown back, prominent abdomen, head rather rigid, legs apart, 
and varying degrees and combinations of bow-legs and knock-knee with 
flat-foot. The cause of this attitude, according to Lovett, may in a 
measure be a persistence of the infantile position which children assume 
when they are learning to walk. 

Children with rhachitis have weak muscles as well as weak bones, 
and the condition of such a child approaches that of one who stands and 
walks with the least expenditure of muscular force. 

Hydrocephalus. — The diagnosis between the rhachitic head and the 
hydrocephalic is usually not difficult. The former is irregularly enlarged, 
flattened on top, square-looking, and has a normally tense or depressed 
fontanelle. The latter is regularly enlarged and rounded, with a tense 
and bulging fontanelle. 

Prognosis. — The prognosis of rhachitis is favorable, provided no com- 



DISEASES OF NUTRITION. 341 

plications arise. When left untreated the disease may, after a decided de- 
gree of deformity has occurred, be arrested spontaneously, the pathologi- 
cal process in the bones cease, and the bones harden in their deformed 
condition (Lovett). In these untreated cases the younger the child the 
more unfavorable is the prognosis. A spontaneous arrest of the disease 
may take place in any of its stages, but, as a rule, if the affection is at all 
pronounced, serious deformities are usually produced. If a hydrocephalic 
condition, which at times appears in rhachitis, is present to any degree, if 
there is much diarrhoea, or if the infant is subject to frequent attacks of 
bronchitis, the prognosis is very unfavorable. Rhachitic children are more 
liable to die than other children when they are attacked by such diseases 
as pneumonia or bronchitis. Attacks of the acute exanthemata are of 
serious import in these cases. Rhachitic children are especially liable to 
the invasion of the tubercle bacillus. According to Bradford and Lovett, 
kyphosis disappears under proper treatment. Lateral curvature is per- 
manent when not treated. As a rule, the epiphyseal enlargements 
diminish with growth, but to a certain degree remain through life. The 
craniotabes, laryngismus stridulus, bronchitis, diarrhoea, and paralysis 
gradually in the favorable cases pass away. Although rarely, death may 
occur in attacks of laryngospasmus and convulsions in rhachitic infants. 

When properly treated, the health of rhachitic children improves 
slowly, and, unless the deformities which have occurred in the bones 
have advanced too far, more or less complete recovery usually takes place 
in the third or fourth year. The arrest of the disease at an early stage 
is important. 

Treatment. — The treatment of rhachitis is essentially dietetic and 
hygienic. The infants should be kept in the open air as much as pos- 
sible, and should live in rooms accessible to sunlight. The food should 
be adapted to the age, according to the rules given for the feeding of 
normal infants during the first two years of life. There does not appear 
to be any drug which produces a specific effect upon the osseous changes 
which take place in rhachitis. Phosphorus is considered by some ob- 
servers to be a valuable adjunct to the general dietetic and hygienic treat- 
ment, but, according to our experience at the Children's Hospital, it has 
not proved to be of any especial benefit. 

When the anaemia is marked, iron in some form should be given, and 
at times an increase in the fat in the food seems to be beneficial. Espe- 
cial attention should be paid to the correction of deformities by exercises 
and if necessary by surgical interference. Whenever any tenderness or 
pain is noticed, the infant should at once have orange-juice given to it, as 
directed in scorbutus (page 347). 

Laryngospasmus should be promptly treated by sprinkling the face 
and chest with cold water and by lightly slapping the back. 

Convulsions should be treated with unusual care in a rhachitic child, 
in whom they usually arise from depression and resulting over-sensitive 



342 PEDIATRICS. 

condition of the nervous system. Stimulants are usually indicated in 
these cases. 

Fig. 87, I. and II., represents unusually well the deformities in the 
bones which may arise as a result of rhachitis. 

The boy was six years old. He was nursed from the breast for two years, and 
then given a general diet. He began to walk when fourteen months old, and the 
mother noticed that his legs began to bend at about that time, but could give very little 
information about the course of the disease. The physical examination showed the 
heart's impulse to be about on the level with the sixth rib and in the mammillary 
line. The heart's sounds were clear and loud. Nothing abnormal was detected in the 
throat or lungs. The abdomen was large, prominent, and tympanitic ; the liver was 
palpable three fingers' breadth below the ribs in the mammillary line ; the spleen was 
not palpable. 

Looking at the child from in front, as represented in Fig. 87, I., the head was 
square with enlarged frontal prominences. There- was a decided bowing of the left clavi- 
cle with enlarged epiphyses of the wrists and ankles, outward bowing of the femora, 
and flat-foot with extreme pronation. The side view, as represented in Fig. 87, II., 
shows the flattened top of the skull, rhachitic rosary, distended abdomen, lordosis, an- 
terior bowing of the tibiae, and flat-foot. 

CHONDRODYSTROPHIA FCETALIS. 

There is a fcetal or congenital condition which shows a general simi- 
larity to the bone changes of rhachitis. There have been a number 
of cases. Kaufmann reports cases of his own, and suggests the name 
chondrodystrophia fcetalis. These cases are by some writers considered 
not to be rhachitis at all, while some of the cases reported show histo- 
logical conditions similar to those found in acquired rhachitis. Vierordt 
is inclined to think that this is hardly evidence enough, as we know that 
similar changes may be produced experimentally which are not actually 
rhachitic, and he considers the existence of a fcetal or congenital rhachitis 
very doubtful. 

In these cases of chondrodystrophia fcetalis the periosteal changes seen 
in rhachitis are absent, and the epiphyseal changes do not correspond 
accurately to the rhachitis of extra-uterine life. I have seen a case of 
supposed congenital rhachitis in which the rhachitic process had run its 
course and the hardening of the bones had apparently been completed 
before the infant was born, but such cases I now consider examples of 
chondrodystrophia fcetalis. 

Another case which formerly would have been considered one of 
congenital rhachitis was seen by me in consultation with Dr. Townsend. 

The parents were young and healthy, and there was no history of syphilis or rha- 
chitis. The father was American, the mother Scotch. There was one other child, 
three years old, strong and well. The mother during her pregnancy was much wor- 
ried, and her nourishment was both insufficient and poor. The infant, a male, was 
one month premature. The labor was easy. The infant weighed seven pounds and 
was 43.3 cm. (17 inches) in length. 



Fig. 87. 




Rhachitis. Age, 6 years. 



DISEASES OF NUTRITION. 



343 



Fig. 88 represents a photograph taken on the fourth day of the infant's life. The 
head was square in front, was much flattened behind, and measured 33.8 cm. (13£ 
inches). The sutures were all widely open. The ossified portions of all the bones of the 
skull were small, particularly of the occipital bone, which presented a large area of 

Fig. 88. 




Congenital rhachitis: 

craniotabes. In the widely opened sagittal suture just back of the anterior fontanelle 
was a large Wormian bone 2.7 cm. (1 inch) long. In the squamous and coronal su- 
tures on the right side at least eight small Wormian bones could be easily felt, and on 
the left side eleven were counted. The thorax was 30 cm. (llf inches) in circum- 
ference, and was depressed laterally, the depression increasing with each inspiration, 
owing to an accompanying atelectasis in the lower portions of the lungs. There was 
considerable cyanosis. No cardiac murmur was detected. A rhachitic rosary was 
present. The abdomen measured at the level of the umbilicus 28.7 cm. (11 \ inches). 
There was a large double inguinal hernia. The spleen could not be detected on ex- 
amination. The liver could be felt below the edge of the ribs, but was apparently 
not enlarged. There were marked enlargement of all the epiphyses, curvature of 
all the long bones, and numerous fractures. The humeri showed a slight anterior 
curvature. The bones of each forearm were also bent anteriorly. The femora were 
curved outward and,forward. The lower legs showed marked angular curvatures for- 
ward at the junction of the middle and lower thirds. The fractures were apparently 
of as recent origin as the birth, as some of them proceeded to unite very quickly. On 
the eighth day the fracture of the right tibia was quite firmly united ; and only a 
slight crepitus could still be felt over the left tibia. The fracture of the left hu- 
merus was firmly united with a ring of callus. The right humerus at birth showed a 
callus about the middle of the shaft : this was evidently the repair of an intra-uterine 
fracture. The child died on the ninth day after birth. 



OSTEOMALACIA. 

Osteomalacia is a disease which occasionally occurs in children, but 
not so frequently as in adults. It causes softening of the bones, and in 
this respect is somewhat similar to rhachitis. 

Etiology. — Nothing definite is known about the cause, and it is simply 



344 PEDIATRICS. 

spoken of in connection with diseases of nutrition on account of its re- 
semblance to rhachitis. 

Pathology. — There is, according to Ziegler, an absorption of lime-salts, 
beginning first at the medullary cavity and proceeding outward. The 
epiphyses are not notably affected by the continuance of the absorptive pro- 
cess, the cortical bone becomes spongy and decalcified, and in the severest 
cases there may remain little but marrow and periosteum (J. C. Warren, 
" Surgical Pathology"). 

The opinion is generally held that in osteomalacia the layer of osteoid 
tissue results from decalcification, while in rhachitis a similar layer repre- 
sents a new growth deficient in lime-salts. The periosteum is likely to 
be thickened and vascular, and the medulla resembles that in infancy in 
its gross appearance. 

Symptoms. — Spontaneous fractures and various distortions may occur 
in osteomalacia, and the thorax is flattened laterally. 

Treatment. — The treatment is the same as in rhachitis (page 341). 

SCORBUTUS. 

Scorbutus (scurvy) is a constitutional disease closely associated with 
imperfect nutrition and having a definite relation to the deprivation of 
the individual of fresh food. It is characterized by anaemia and a ten- 
dency to hemorrhage, and in most cases is accompanied by the condition 
of the gums which is present in stomatitis ulcerosa. 

Etiology. — In addition to the view that the cause of scorbutus is of 
chemical origin, owing to the significant relation which the disease has to 
a lack of fresh food, it is supposed that there may be a special micro- 
organism which causes the disease. This, however, has not been proved, 
and we have no further knowledge regarding the etiology of scorbutus. 

In my experience there is no evidence that sterilized milk is a cause 
of scorbutus. If the milk is properly modified it can be heated to 75° 
C. (167° F.), or even to 100° C. (212° F.), without, so far as I am aware, 
having a deleterious effect upon the osseous system. 

Pathology. — So few post-mortem examinations have as yet been 
made on infants dying of scorbutus that the pathological lesions have not 
been finally established. A sufficient number of autopsies, however, has 
been reported by Barlow and others, notably Northrup, to settle at least 
the more important features in the pathology of infantile scorbutus. 

There are no alterations in the blood, either anatomical, chemical, or 
bacteriological, which can be considered peculiar to scorbutus. There 
are deep hemorrhages into the muscles and occasionally about or even 
into the joints, but the hemorrhage in infantile scorbutus is essentially 
subperiosteal and chiefly of the long bones. The femora are most com- 
monly affected, and there is a tendency to separation of the epiphyses. 
There may also be a varying amount of interstitial hemorrhage in the 
lungs, spleen, kidney, and intestinal glands. Hematuria has been noticed 



Pig. 89. 




Vertical section of leg in a case of infantile scorbutus. The red areas around the femur and tibia 
represent subperiosteal hemorrhages. (Specimen preserved in the Museum of the College of Physi- 
cians and Surgeons, New York.; - Page 345. 



DISEASES OF NUTRITION. 



345 



in a certain number of cases of scorbutus, and it is well to examine the 
urine in cases in which the disease is suspected. Hemorrhages into the 
mucous surfaces are usually present, the gums being chiefly affected and 
presenting the condition of stomatitis ulcerosa. 

Fig. 89 represents a section of the bones of the leg in a case of infantile scor- 
butus which was under the care of Dr. Northrup. On examination it will be seen that 
the femur is normal at its upper extremity. The lower half is invested with a black, 
grumous, sub-periosteal layer of blood. The lower epiphysis is detached, and the 
lower end of the shaft, macerated, eroded, and soft, is lying loose in the black, disin- 
tegrating blood-clot. The tibia is surrounded by thin, dark, hemorrhagic layers be- 
neath the periosteum, and the proximal portions are congested. The fibulae and the 
bones of the upper extremities were normal. 

Fig. 90 represents a microscopic section of this bone, which shows no syphilitic 
or rhachitic changes in the bone or the periosteum. 

Fig. 90. 




Section of scorbutic bone. Med., medulla; B, bone; Hem., hemorrhage; Per., periosteum. 

The soft macerated bone gave no evidence of suppuration, but there was a mod- 
erate congestion of the femur and the upper extremity of the tibia. 

Symptoms. — The symptoms of infantile scorbutus are those of a slow 
and progressive cachexia. The infants become anaemic, and show more 
or less gastro-enteric disturbance of a subacute functional type. Profuse 
sweating, especially about the head, at times slight feverish attacks, and 
lessened appetite, are among the early symptoms. The temperature may 
be from time to time slightly raised, but not significantly so. The first 
symptom, however, which especially attracts the attention is a sensitive 
condition of the bones. The infant cries when the affected parts are 
touched. It does not seem to suffer pain when it is allowed to remain 
quiet, but as the disease advances the expression of its face indicates the 



346 PEDIATRICS. 

fear of being handled. My individual experience with infantile scorbutus 
has been derived from seventy to eighty cases, all of which, with few ex- 
ceptions, were from eight to twelve months of age. I met with no cases 
later than the first half of the second year, and with none earlier than the 
second half of the first year. 

As the disease progresses, more marked symptoms develop. Swellings 
of the limbs, usually of the diaphyses just above the epiphyses, appear. 
These swellings are most common and most prominent in the legs, but 
may also appear in the bones of the forearm. They are usually pyri- 
form and symmetrical in shape, the skin over the swelling being more or 
less tense, but not fluctuating. There is commonly some tenderness on 
pressure, but, as a rule, no especial heat of the affected part. The pain 
and swelling do not seem to be in the joint, but in the diaphysis and 
epiphysis. Signs of hemorrhage may occur in the skin over the affected 
parts, appearing at first as small blue maculae and later involving larger 
areas, as though a deep hemorrhage were coming to the surface. In 
advanced cases hemorrhage may take place to such an extent in the 
deeper parts around the eyes that the eyes will be pushed forward 
(proptosis). 

When the infant has not cut any teeth, the mucous membrane of the 
gums, according to my experience, has not been affected ; but when a 
tooth is pressing on the gum and is almost through, or even when a small 
portion of a tooth has penetrated the gum, small areas of congested mu- 
cous membrane appear, and are of great aid in the diagnosis. In some 
cases a few hemorrhagic maculae appear in other parts of the skin, as in 
that of the forehead. 

In addition to the symptoms of epiphyseal pain, the infant keeps the 
affected limb perfectly still, so that, unless it were understood that it is 
pain which prevents it from moving the limb, it might be supposed that 
it was paralysis ; in fact, this symptom in scorbutus has been termed 
pseudo-paralysis. It has nothing to do with true paralysis, and corre- 
sponds to what is seen in rheumatic affections of the joints. 

Diagnosis. — The diagnosis of infantile scorbutus is to be made from 
rheumatism, rhachitis, purpura, syphilis, and acute anterior poliomyelitis. 

Rheumatism. — In the diagnosis from rheumatism the absence of heat 
and tenderness of the joint and of a pronounced rise of temperature is 
usually sufficient to distinguish the two diseases. 

Rhachitis. — The diagnosis from rhachitis is to be made by the presence 
of hemorrhages, the intense pain in the region above the epiphyses, the 
absence of a rhachitic rosary, and the absence of symptoms of rhachitis 
when it is not coexistent. If teeth are present, the occurrence of stoma- 
titis ulcerosa usually makes the diagnosis clear. In the cases in which 
rhachitis is present the symptoms of scorbutus appear to complicate a 
primary rhachitis, and when the scorbutic symptoms pass away fhe rha- 
chitic manifestations remain. 



DISEASES OF NUTRITION. 347 

Purpura. — Purpura, except in the severe forms in which the joints are 
affected, is easily differentiated by the absence of the peculiar osseous 
symptoms of scorbutus. 

Syphilis. — Scorbutus is differentiated from syphilis by the extreme 
tenderness, the hemorrhages, and the commonly occurring stomatitis 
ulcerosa which occur in the former disease, while syphilis has distinctive 
symptoms which are not found in scorbutus, which will be described under 
the former disease. 

Acute Anterior Poliomyelitis. — The differential diagnosis between scor- 
butus and acute anterior poliomyelitis is made by the presence in the 
former of enlargement and tenderness in the neighborhood of the epiph- 
yses. Pain is present only in the initial stage of acute anterior polio- 
myelitis, and tenderness is absent. In acute anterior poliomyelitis, also, 
the onset is sudden, and there are no premonitory symptoms. 

Prognosis. — Scorbutus is very variable in its duration. If left un- 
treated, all the symptoms may become more pronounced and the infant 
finally die of exhaustion. When properly treated, and uncomplicated by 
any other disease, the prognosis is very favorable if treatment is begun 
early in the attack, before the vitality of the infant has been too much 
reduced. 

Treatment. — The treatment of infantile scorbutus is essentially by 
changing the improper food which in most cases is being given, to fresh 
milk and orange-juice. Under this treatment the pain and tenderness of 
the limbs rapidly disappear, sometimes within a few days, as does also 
the stomatitis ulcerosa. In the beginning the juice of one orange should be 
given during the twenty-four hours. It usually is well to dilute the orange- 
juice one-third with water. If a rapid improvement does not take place, 
a still larger dose should be given within a few days. These scorbutic in- 
fants usually take orange-juice with avidity, but they should be forced to 
take it if they do not like it. The nurse should be cautioned to move 
the affected limbs as little as possible, and the infant should be kept on a 
comfortable pillow on which it can be carried about. 

In my earlier cases, before I recognized the scorbutic element in the 
disease, I treated these infants with a number of drugs, none of which 
appeared to have the slightest beneficial effect. In some of these cases 
the symptoms grew progressively Avorse, and the infants died. In one of 
them, however, in whom the hemorrhages in the skin were extensive and 
proptosis was marked, the infant recovered entirely when a properly 
modified milk was substituted for the artificial food which it had been 
taking. In some of the later cases which I have seen in consultation, where 
infants living in the country with good hygienic surroundings were being 
fed on one of the many artificial foods, the disease had progressed to 
such an extent that the infants were extremely anaemic, had hemorrhages 
in various parts of the skin, were unable to take any food, and were 
seemingly dying ; in fact, they were as much reduced as were the cases 



348 PEDIATRICS. 

which I have just spoken of as having terminated fatally. These infants, 
after taking orange-juice for a few days, invariably improved rapidly, and 
usually recovered entirely in two or three weeks. 

All my cases have presented in different degrees the symptoms which 
I have just described, and which are well represented in the following 
case and in Fig. 91 : 

The infant, a female, ten months old, was healthy at birth and weighed 3636 
grammes (8 pounds). It was nursed at first, but later was fed on a patent food, on 
which it did not gain. When it was eight months old it lost somewhat in weight, had 
profuse sweating, and began to have tenderness in its limbs. It had six teeth. There 
was an expression of fear on its face, and it kept its arms and legs perfectly motion- 
less. 

Pig. 91. 




Infantile scorbutus. (Second month of disease.) Female, 10 months old. 

Whenever it thought that its legs or arms were going to be touched it cried with 
fear. There was no evidence of rhachitis in this infant. There was a swelling of the 
diaphysis just above the epiphyses of the bones of the right wrist, and also in the 
lower part of the femur of each leg and the lower part of the tibia. The swelling did 
not fluctuate, had a hard, tense feeling, and apparently was not connected with the 
joints. There was no increased heat of the skin, but there were certain circumscribed 
areas of hemorrhage in the skin over the swellings. The gums showed the condition 
of stomatitis ulcerosa to so marked a degree that they almost covered the teeth. They 
were purple, bled easily, and were very similar to those represented in Plate XL, 
facing page 620. 

The infant's diet was changed to a modified milk, and it was given the juice of 
one orange daily. Within two days it moved its legs and arms freely, the anxious ex- 
pression left its face, and in a few weeks it had gained much in weight and was 
perfectly well. 

An examination of the blood in this case showed only a secondary 

anaemia. 

INFANTILE ATROPHY. 

Infantile atrophy (marasmus, athrepsia) is essentially a disease of in- 
fancy and early childhood, and occurs most frequently in the first six 
months of life. It is a condition in which extreme atrophy of all the soft 
tissues takes place without demonstrable disease of any of the organs. It 
is apparently the result of a vice of absorption, although this has by no 



DISEASES OF NUTRITION. 349 

means been clearly proved. The wasting which occurs as the result of 
malformations of the mouth and throat preventing the entrance of suffi- 
cient food, or when insufficient food is given, should be considered as the 
result of starvation. The name infantile atrophy should be restricted to 
the cases in which such causes do not exist. In like manner the wasting 
which occurs in the course of constitutional diseases, such as tuberculosis 
or syphilis, or as the result of severe gastro-enteric disturbance, is not to 
be considered under the name of infantile atrophy. 

Etiology. — The cause of the primary cases of infantile atrophy is un- 
known. In a number of cases the disease seems to be secondary to grave 
intestinal disturbance, whether of toxic or of organic origin. The disease 
appears to depend upon improper diet or bad hygienic surroundings, either 
separately or in combination. Thus infants may develop the disease 
whose food is seemingly good but whose surroundings in crowded cities 
or districts are unhygienic as to light, warmth, pure air, and air space. On 
the other hand, the disease is at times met with in the country where the 
hygiene is good but the food poor. 

Pathology. — The pathological conditions which are found in cases of 
infantile atrophy are exceedingly unsatisfactory, and have not given us 
much information concerning the disease. Nothing abnormal is found in 
the various organs which can be said to be characteristic of this disease. 
It is supposed by some pathologists that the lymph-glands are enlarged, 
but this enlargement does not seem to be a prominent feature, and is 
chiefly confined to the superficial glands of the neck, axillae, and groins. No 
pathological condition of the mesenteric lymph-glands has been found, and 
the atrophy of the mesentery around them is so great that their increase 
in size may be seeming rather than real. In the intestine, although in 
some cases there is considerable atrophy of the mucous membrane and 
the submucous tissue, no characteristic lesion has been proved to be pres- 
ent. Therefore, until our knowledge of the pathology of this disease be- 
comes more definite, it is better for us to consider its pathology as simply 
atrophy. Certain secondary morbid conditions are frequently found. 
Prominent among these are anaemia, atelectasis in the lungs, bronchitis, 
broncho-pneumonia, fatty liver, and intestinal catarrh. 

Symptoms. — The essential symptom of infantile atrophy is extreme 
wasting. An infant which has perhaps been weak and delicate, or may 
have been seemingly well nourished, begins to emaciate. The prominent 
feature of the disease is the progressive and extreme loss of weight. The 
loss of subcutaneous adipose tissue is excessive, the skin is dry and wrin- 
kled, and hangs in folds on the bones, giving the appearance of a living 
skeleton or advanced old age. The extremities are cool. The abdomen 
soon becomes sunken. The tongue is dry and usually reddened. The 
pulse is feeble and usually rapid. The temperature is normal, or more 
commonly subnormal, but in some cases is raised. The respirations are 
generally normal. Although secondary anaemia is quite a prominent con- 



350 PEDIATRICS. 

dition, extreme pallor is not usual. The appetite is usually lessened, but 
may be at times voracious. In many cases the food is well digested, and 
the discharges yellow and smooth. In some cases the total amount of the 
faecal discharges in twenty-four hours is abnormally large. Regurgitation 
of food is common, and at times vomiting of a reflex nature becomes 
prominent. The normal faecal discharges at times are abnormal in color 
and consistency. In advanced cases ecchymoses may appear in the skin, 
sometimes covering the entire thorax. 

Diagnosis. — The diagnosis of infantile atrophy is chiefly to be made 
from ordinary starvation and from general tuberculosis. From the former 
it is soon differentiated by its lack of response to good food and improved 
hygiene. In the ordinary cases of starvation which result either from 
improper food, or from lack of food, a diet carefully adapted to the age of 
the infant or child is soon followed by rapid improvement. The cases 
of wasting from mechanical causes are recognized by detecting the special 
malformation which is present. Those cases which are secondary to 
other diseases are differentiated from the primary cases of infantile atrophy 
by the prominence in the history of the essential symptoms of such dis- 
eases. In other words, in these cases the wasting is not the one essential 
symptom. 

The differential diagnosis from general tuberculosis is at times exceed- 
ingly difficult. I have had under my care in the hospital in adjacent 
beds an infant with infantile atrophy and one with general tuberculosis. 
In these two cases the symptoms and courses of the diseases were iden- 
tical, and it was impossible to differentiate the two diseases except at the 
autopsy. On physical examination nothing abnormal could be found in 
either case except extreme emaciation. In both cases the temperature 
was slightly raised. The physical examination from tuberculosis, there- 
fore, if the temperature is raised, is almost impossible, as complicating 
processes in the lungs may produce evidence of solidification in infantile 
atrophy. Where, however, solidification is prominent in the front of the 
lungs, it is most likely to arise from tuberculosis. The presence or ab- 
sence of the tuberculin reaction will in many cases be needed to differ- 
entiate the two diseases. 

Prognosis. — The prognosis of infantile atrophy is bad, especially during 
the first year of life. Even under the most careful treatment it is always 
a very intractable disease. Even the most exact modification of the 
food at times entirely fails to cure the disease. When, however, the infant 
recovers, the recovery is usually complete, and perhaps within a year the 
child may show no signs of the previous serious condition. 

Treatment. — The treatment of infantile atrophy is essentially by such 
modification of the milk as to promote intestinal absorption, and without 
drugs. Especial attention should be paid to keeping up the bodily tempera- 
ture by external warmth and by the administration of stimulants. Small 
doses of brandy can often be given for weeks with great benefit. 



DISEASES OF NUTRITION. 351 

Although, as has already been stated, it is not entirely proved that the 
morbid condition is that of a lack of absorption, yet my clinical results are 
most favorable when the disease has been treated on this principle. After 
experimenting in a large number of cases by modifying the different con- 
stituents of the milk in various ways, I have arrived at the following con- 
clusion : a mixture should be given which contains a low percentage of 
fat, a high percentage of sugar, and a moderate percentage of proteids. 
The low percentage of fat is given on the supposition that the infant will 
increase in weight and thrive on a small proportion of fat, provided it is 
absorbed. I have found that when higher percentages of fat are given the 
infant continues to lose in weight. The administration of cod-liver oil 
is not indicated in these cases, for it is only by a precise adjustment of 
the percentage of the fat in the food to the individual power of absorption 
that good results can be obtained. The sugar of high percentage and the 
proteids of normal percentage seem to be digested and absorbed provided 
they are combined with a low percentage of fat, since by this combina- 
tion the nutritive properties of the sugar and of the proteids are made use 
of. The prescription which I usually write in the beginning of the treat- 
ment of these cases, when they occur in the first year of life, is the fol- 
lowing : 

Prescription 52. 

Fat 0.50 

Sugar 6.00 

Proteids (lactalbumin 0.75, caseinogen 0.25) 1.00 

Lime-water . . 5.00 

After the infant has begun to gain in weight I usually increase the 
percentage of the fat, but for a number of weeks I do not raise this per- 
centage above 1 or 2. When the infant has once begun to gain steadily 
the power of absorbing fat is rapidly regained, and percentages such as 
are in the following prescription can then be given : 

Prescription 53. 

Pat 3.00 

Sugar , 7.00 

Proteids 2.00 

Lime-water 5. 00 

The same treatment can be carried out when the disease occurs in 
children in their second and third years, but in these cases it is usually 
possible to increase the percentages of the different elements more rapidly, 
and after two or three weeks to begin with other articles of diet, such as 
beef-juice, broths of various kinds, and finally, with caution, cereals. 

These special modifications of the milk do not, of course, suit every 
individual infant or child, and when the treatment with them is not suc- 
cessful, each of the elements of the milk must be carefully changed and 
different combinations of these elements tried until the individual idiosyn- 
crasy of absorption in the special case has been discovered. A very im- 



352 



PEDIATRICS. 



portant part of the treatment is the general hygiene, especially sufficient 
air space and pure air. 

The following cases illustrate infantile atrophy of high grade. 

An infa?it nine months old had been fed on foods of various kind?, all of which 
contained a considerable percentage of starch. She is said to have been healthy and 
plump at birth and during the early months of life while she was nursed. After she 
was weaned and placed on starchy foods she began to lose progressively in weight, and 
became extremely emaciated. Physical examination showed nothing abnormal. She 
had four teeth. Her temperature was slightly subnormal, her pulse was regular but 
weak, her respirations normal. On first entering the hospital the bowels were consti- 



Fig 




HHBB 

Infantile atrophy. Female, 9 months old. 

pated and the faecal movements were brown and looked poorly digested. On being 
placed on a diet of modified milk the movements became well digested and of normal 
color, but the total amount in twenty-four hours was greater than usual. She was 
very fretful, and at times vomited, but when her diet was regulated she became less 
fretful and somewhat apathetic. On entering the hospital she weighed 2966 grammes 
(6£ pounds). She was in the hospital two weeks, and gained in that time 1000 
grammes. The food which was found to suit her powers of absorption contained fat 1, 
sugar 5, proteids 1, lime-water 5, and 60 to 120 c.c. (2 to 4 ounces) were given every 
two hours. 

She did not increase progressively in weight, but sometimes lost considerably, and 
once it seemed as though she could not possibly live. After the food had been modi- 
fied in various ways, she finally began to improve, and when she was able to digest 
and absorb 150 c.c. (5 ounces) of milk so modified as to contain fat 3.5, sugar 6.5, and 
proteids 1.5, she improved rapidly, and eventually recovered entirely. Her tempera- 
ture, with few exceptions, was normal or subnormal through the whole course of the 

attack. 

Pig. 




Infantile atrophy. Female, 10 months old. 

This next case was also one of infantile atrophy of high grade. 
An infant 10 months old entered the hospital with a history of having been fed 
on various foods containing starch from the earliest months of its life. It was said 



DISEASES OF NUTRITION. 358 

to have been healthy at birth and of average weight. On entering the hospital it 
weighed 2593 grammes (5| pounds). It was extremely emaciated, and illustrated the 
more advanced stage of infantile atrophy. It was unable to raise its head and was 
apathetic ; its skin was cool and dry ; its respirations were shallow ; its pulse was 
weak, and its temperature was slightly subnormal. It looked as though it could not 
live many days. A physical examination showed nothing abnormal in any of the 
organs. The faecal movements were rather large in amount, but when its food was 
carefully regulated, became fairly well digested. On entering the hospital they were 
still larger in amount and were of a brownish color. It weighed, after being in the hos- 
pital one week, 2570 grammes (about 5£ pounds), which was slightly less than its 
weight on entrance. It was fed on a modified milk in which the percentage of fat was 
2, sugar 6, proteids 1, lime-water 10. 

In two weeks the infant began to gain in weight and to absorb its food. Although 
it had a number of relapses, in which it lost considerably in weight, it finally began to 
gain steadily. At the end of three months it had recovered entirely, and was quite 
plump. In this case the percentage of the fat was finally raised to 4, and that of the 
sugar to 7, but the proteids had to be kept at 1 ; the lime-water was reduced to 5. 

The next case was a female, one and a half years old, who, on entering the hos- 
pital, weighed 4281 grammes (9J pounds). She was said to have weighed but 900 
grammes (2 pounds) at birth. She was nursed by her mother, who apparently had 
plenty of good breast-milk, and who had two other children whom she had nursed 

Fig. 94. 




Infantile atrophy. Female, 1% years old. 

that were healthy and strong. As the infant did not gain, she was nursed for only a 
short time, and was then fed on various artificial foods. She began to lose in weight, 
and this loss continued so that her emaciation was extreme. 

On physical examination the anterior fontanelle was found to be widely open. 
There was no enlargement of the epiphyses of the ankles or wrists, but there was a 
slight rhachitic rosary. Nothing abnormal could be detected in any of the organs. She 
had four upper and two lower incisors. She was very apathetic, and seemed hungry, 
but when food was given to her she vomited. After entering the hospital she lost 519 
grammes (It pounds) in two weeks. Her skin was dry. harsh, and at times quite 
cold. The faecal movements were very large in amount, but after entering the hos- 
pital were fairly digested. The cervical and inguinal glands were slightly enlarged and 
she had a slight cough. She lost steadily in weight, did not respond to the various 
modifications of the milk given to her, and died three weeks after entering the hospital. 

The post-mortem examination showed the following condition : There was ex- 

23 



354 



PEDIATRICS. 



treme atrophy of all the muscles. There were no changes in the mesenteric glands, 
and they were not enlarged, although the extreme atrophy of the mesentery around 
them made them appear so. The liver was normal and its tissue showed little 
evidence of atrophy. The spleen was normal. Sections made from various places in 

Fig. 95. 




Infantile atrophy, showing extreme emaciation of arms, back, and hips. 



the stomach and the intestines showed no changes beyond considerable atrophy of the 
mucous membrane of the submucous tissues. The thyroid gland was atrophied. 
There was an extensive bronchitis in the posterior portion of the lungs, while in some 
parts there was a partial, and in others, a complete atelectasis. 



DIVISION VII. 

DISEASES OF THE SKIN. 



The rule that the child should be inspected in every part is very im- 
portant, and is especially applicable to cases in which there is disease of 
the skin. 

The lesions of the skin in children differ somewhat from those which 
occur in adults, and these variations, both in degree and in kind, often 
make a differential diagnosis more difficult. Every practitioner has doubt- 
less been struck by the similarity which at times is seen in the cutaneous 
lesions of the various forms of erythema to such diseases as syphilis, scar- 
let fever, and erysipelas. I have known the delicate pink of an abdomi- 
nal erysipelas in a young infant mistaken so completely for scarlet fever 
that the precaution of removing the carpet in the room had already been 
taken. In like manner a slight grade of the efflorescence of scarlet fever 
may be mistaken for that of erythema neonatorum. I have also seen a 
harmless papular erythema closely simulating and mistaken for one of the 
papular efflorescences of syphilis. The efflorescences which follow the 
administration of antitoxin also closely simulate scarlet fever, measles, and 
the different forms of erythema. 

Another rule, and one of equal importance, is that no single dermal 
lesion, whether it be a macule, a papule, a vesicle, or a pustule, makes it 
justifiable for us to decide that an especial disease is present. We must 
remember that the same cutaneous lesion may appear in almost any dis- 
ease, and that it is the combination of dermal lesions and general symptoms 
which makes up the entire picture of the disease and justifies us in making 
a diagnosis. 

It is very important, therefore, to have a fair, general knowledge of the 
local diseases of the skin as they appear in children, in order that a correct 
differential diagnosis can be made from the constitutional diseases with 
dermal lesions, which have to be treated by those who practise among 
children. 

SCABIES. 

Scabies represents the purest type of a primary disease of the skin. 
It is caused by an especial parasite, the Acarus scabiei. The following 
case illustrates the disease : 

355 



356 PEDIATRICS. 

The child, two and a half years old, was healthy and well developed. For two 
weeks it had been very irritable, and its mother brought it to the hospital to inquire 
about an efflorescence which had appeared on its skin. On investigating the lesions a 
number of small papules and a few pustules scattered irregularly over the arms and 
chest, and one or two small pustules on the soles of the feet were found. The fingers 
were not especially affected, but in one or two places at the base of the fingers the efflo- 
rescence could be plainly seen. In addition to the papules and pustules there were 
numerous lesions of the skin caused by scratching. On the delicate skin of the abdomen 
was a minute black line with a vesicle at one end of it. On removing carefully with a 
needle a little of the fluid in this vesicle and placing it under the microscope, the para- 
site, which evidently had its habitat in the vesicle, could be seen. This organism, which 
I shall not describe more fully, as it is best studied in works especially devoted to diseases 
of the skin, is called the Acarus scabiei, and is the cause of this special dermal lesion. 
The black line represented the burrow by which it enters and through which it travels as 
far as the vesicle, where it lodges and produces irritation, causing first a minute papule, 
and then a minute vesicle. Finally the vesicle may become pustular. In this case, the 
child's mother showed the lesions of scabies between her fingers. 

In contradistinction to the effects of the Acarus scabiei on the skin of 
adults we find in infants and young children that the parasite may attack 
the soft skin of the soles of the feet, while in the adult we do not find 
the lesions on the soles, as in walking the skin has become toughened in 
that locality. In adults efflorescences on the soles of the feet and the 
palms of the hands are rather unusual unless they are connected with 
syphilis or artificial eczema. Infants and young children are usually in- 
fected by the Acarus scabiei from sleeping in the bed with some adult who 
has scabies. 

Treatment. — In the treatment of this disease it is very important to 
treat it in the mother as well as in the child. The clothes of the bed, of 
the mother, and of the infant should first be thoroughly steamed, in order 
to kill the parasite, and it should be impressed upon the mother that the 
treatment must be carried out very carefully, and that all the clothes 
which have come in contact with the skin must be thoroughly cleansed. 

The treatment of scabies in the child should differ somewhat from that 
which is employed when the disease occurs in the adult, because the skin 
of the former is much more sensitive than that of the latter. The severe 
remedies which can properly be used in treating the adult should not 
be employed in the treatment of infants and young children. 

A simple and effective ointment recommended by Bowen is as follows : 

Prescription 54. 
Metric. Apothecary. 

Gramma. 
R Balsami Peruviani, J R Balsami Peruviani, 

Petrolati aa 60) Petrolati aa ^ ii. 

M. M. 

For older infants and children an ointment containing some sulphur 
may be employed without much danger of irritating the skin. 



DISEASES OF THE SKIN. 357 



Prescription 55. 
Metric. Apothecary. 

Gramma. 

B Sulphuris sublimati 3 if ; 

Balsami Peruviani, 

Petrolati aa ^ i. 



B Sulphuris sublimati 7 

Balsami Peruviani, 

Petrolati aa 30 



M. M. 

In the use of either of these ointments the following technique should 
be employed. The child is to be first thoroughly washed with warm 
water and soap. The skin is then dried, and the ointment is applied over 
the whole body, avoiding the head, which is seldom attacked by the 
parasite. The face especially might be irritated by the ointment. The 
ointment is allowed to remain on the child during the night, and in the 
morning is washed off with warm water and soap. The skin is then 
thoroughly powdered with the zinc and starch powder mentioned on page 
98. This treatment is continued for three or four days, and then, if the 
disease is not entirely cured, it can be repeated for a few days more. 

A certain amount of eczema usually follows .the treatment, owing to 
the irritation produced by scratching, which is very difficult to prevent. 
This eczema should be treated by soothing applications. 

PEDICULOSIS. 

A parasite whose nidus is on the head appears quite frequently in 
children as well as in adults. It is especially met with among the poor 
and ill cared-for. This parasite, the pediculus capitis, causes extreme irri- 
tation of the skin, which often results in eczema and in enlarged glands. 
Although the pediculus itself is in the hair, yet by its irritating action on 
the scalp of the child it frequently gives rise by reflex influence to patches 
of eczema grouped about the nose and ears. 

Treatment. — In treating these cases the hair and scalp should first be 
saturated with petroleum. This application is allowed to remain on the 
head for several hours, and later is thoroughly washed off with soap and 
water. The nits should then be carefully removed by means of a fine 
comb wet with vinegar. It is usually necessary to repeat the treatment 
for two or three days. 

IMPETIGO CONTAGIOSA. 

Impetigo contagiosa is a disease which usually occurs in children, but 
it may be found in adults. It sometimes appears as an epidemic, and in 
these cases, in all probability, is caused by the same micro-organism as in 
the isolated cases. It is usually met with among the poorly cared-for, but 
it may attack the healthy as well as the sick and weak. 

Symptoms. — The form of the efflorescence is variable. Beginning as 
small vesicles, the lesions soon spread over a larger area, coalesce, usu- 
ally form pustules, and later become rapidly covered with a thick yellowish 
crust. The lesion may occur on any part of the body, but is especially 
common on the face and hands. The itching is very slight in these cases, 



358 PEDIATRICS. 

and there is no constitutional disturbance caused directly by the parasite. 
In accordance with the idea that it is of parasitic origin, the prognosis is 
favorable, and the disease can usually be cured in a week or ten days. 

Treatment. — The treatment of impetigo contagiosa is very simple, and 
consists in cleanliness, exposure to sunlight, and the application of an 
ointment such as the following : 

Prescription 56. 
Metric. Apothecary. 

Gramma. 

R Acidi borici 3175 R Acidi borici gi; 

Adipis 3o|()0 Adipis g i. 

M. M. 

FTJRTJNCULOSIS. 

Closely connected with impetigo contagiosa is furunculosis, which is 
supposed to be caused by the same micro-organisms that give rise to im- 
petigo contagiosa, but which affects a different part of the skin, such as 
the deeper portions of the hair-follicle, in contradistinction to the upper 
layers of the skin, the part affected by impetigo contagiosa. These micro- 
organisms are called the " pus organisms," and are usually represented 
by the staphylococcus pyogenes aureus. 

Treatment. — The treatment should be with an antiparasitical oint- 
ment or solution preferably containing boracic acid. In many cases in 
addition to this local treatment some form of constitutional treatment 
should be employed, as the children are usually in an abnormal condition. 
The lesions should be bathed every day with the following solution : 

Prescription 57. 
Metric. Apothecary. 

Gramma. 



R Acidi borici 15 

Aq. destil 240 



R Acidi borici % ss ; 

Aq. destil ^ viii. 



M M. 

After the parts have been thoroughly bathed with this solution the fol- 
lowing ointment should be spread on linen compresses and applied to the 
lesions : 

Prescription 58. 
Metric. Apothecary. 

Gramma. 

R Acidi boraci 3 

Petrolati 30 



75 R Acidi borici g i ; 

00 Petrolati g i. 



M. M. 

MOKLUSCUM OONTAGIOSUM. 
Another probably parasitic disease which is rare, but which is more 
frequent in children than in adults, is molluscum contagiosum. It occurs 
most commonly on the face, although it may be found on other parts of 
the body. The lesions consist of small, firm nodules of a whitish color, 
with a central depression from which matter of a sebaceous consistency 
may be pressed. The diagnosis is not difficult for one who has once seen 



DISEASES OF THE SKIN. 359 

the efflorescence, the only condition with which it might possibly be con- 
fused being verruca, which, however, does not occur commonly on the 
face, has no central depression, and does not contain any substance which 
can be squeezed out. 

Treatment. — The treatment of these lesions is to puncture them, 
squeeze out their contents, and dress them with the same ointment as in 
Prescription 58. 

SEBORRHCEA CAPITIS OF INFANTS. 

Seborrhcea capitis consists of a collection of brownish-yellow crusts 
formed by a mixture of sebaceous matter and epithelial scales on the top 
of infants' heads. It is simply a tendency to over-production by the seba- 
ceous glands of their secretion, which, mixed with dirt, produces this con- 
dition. The whole scalp of the infant should be perfectly clean, and in all 
cases it is safe and best to remove the crusts, as they are frequently the 
starting-point for eczema. Plate III., B, facing page 84, represents this 
condition. The crusts should be gently and gradually removed by first 
soaking them with warm sweet oil, and then washing them off with soap 
and warm water. Some simple ointment should be kept continuously on 
the part affected, to prevent the reaccumulation of the crusts until the ten- 
dency has ceased. 

TTNEA TRICOPHYTINA. 

The disease called tinea tricophytina, or ringworm, occurs clinically in 
two forms. The first form affects the scalp, and is called tinea tonsurans. 
The other form attacks the non-hairy portions of the body, and is called 
tinea circinata. 

The disease itself is called tinea tricophytina, and the parasite which 
causes it is called the tricophyton tonsurans. 

Tinea tricophytina has the peculiarity of not appearing on the scalp 
except in children, but is the same disease that occurs in adults in various 
localities, as on the face in men, destroying parts of the beard. It may 
also occur on any part of the body both in children and in adults. Its 
cause can usually be traced to the same parasitic affection in some other 
person or some animal. 

The second form of tricophytina, tinea circinata, may at times appear 
as numerous multiple lesions in different parts of the body, and is easily 
affected by anti-parasitic applications. 

Treatment. — The treatment of this disease should be active, and it is 

usually necessary to continue it for a long time, especially in cases in 

which the parasite has attacked the head. The treatment should be with 

the following ointment : 

Prescription 59. 

Metric. Apothecary. 

Gramma. 

R Acidi salicylici, | R Acidi salicylici, 

Sulphuris aa 3175 Sulphuris aa ^i ; 

Lanolini 30100 Lanolini J i. 

M. . M. 



360 



PEDIATRICS. 



It should be applied twice daily, and should be thoroughly rubbed 
into the bald spots, the skin first having been washed with soap and 
water. 

When the case proves to be somewhat intractable, still stronger appli- 
cations can be used, and, if necessary, a certain amount of carbolic acid 

can be mixed with the ointment, from 
one-half to one drachm to the ounce of 
ointment. 



Pig. 




Fig. 96 represents a boy, eight years old, 
with two bald spots on the back of his head. 
The hair over the rest of his head was thick, 
and there were no appearances of loss of hair 
anywhere else on his scalp. The areas of scalp 
attacked by this disease vary in size. In this 
special case, however, the spots were about 2.5 
cm. (1 inch) in diameter. As a rule, they have 
a fairly regular circumference. On examining 
the spots one will notice that there are little 
short hairs on their surfaces, which evidently 
have broken off from lack of nutrition. On the 
edges of the spots this is especially noticeable. 
If one of the hairs is placed under the micro- 
scope, one will find a specific organism which 
has been determined to be the cause of this 
disease. It is of vegetable origin, and consists of masses of spores composed of threads 
of mycelium, some long and some short, which are divided into numerous segments. 



Tinea tonsurans 



years old. 



TINEA FAVOSA. 

Tinea favosa, or favus, is a parasitic disease. Its favorite seat is the 
scalp, although it may attack any part of the body. It appears in the form 
of small, bright yellow, cup-shaped crusts, which upon their removal leave 
a permanent but superficial cicatrix. These yellow crusts penetrate the 
hair-follicle and destroy the growth of the hair. When placed under the 
microscope they are found to consist almost entirely of mycelium and 
spores of the form called Achorion schoenleinii. The crusts often become 
confluent, forming a large thick covering over an extensive area. 

Treatment. — The treatment is the application of an ointment to soften 
and remove the crusts, epilation, and anti-parasitic ointments such as 
described for ringworm. 

TTNEA VERSICOLOR. 
This is a very rare disease in children. A case seven and a half years 
old has been reported. It is a parasitic disease caused by the microsporon 
furfur. The lesions consist of patches of fine yellowish scales, usually 
situated on the trunk. There are no subjective symptoms. Paraciticides 
combined as in Prescription 55, page 357, remove the disease very quickly, 
but it is prone to recur. 



DISEASES OF THE SKIN. 361 



ALOPECIA AREATA. 

The nature of the disease alopecia areata has not yet been determined. 
The lesion of alopecia areata consists of an irregular surface of the scalp 
entirely free from hair up to where the long hair begins to grow on its 
edges. The appearance of the skin over this spot is normal. 

The diagnosis is made by finding a bald spot on the head having the 
appearance just described. The remaining part of the scalp is found to 
be in a healthy condition and well covered with hair. 

Alopecia areata is to be differentiated especially from tinea tricophytina. 
In contradistinction to the sound and healthy-looking skin of the former, 
we find in the latter numerous short hairs, which are broken off through 
the action of the parasite. 

Alopecia areata is somewhat intractable to treatment and runs a 
rather long course, but, as a rule, in children can be cured. 

Treatment. — The treatment is the continual application of stimulating 
remedies, such as the following ointments of sulphur and tar : 

Prescription 60. 
Metric. Apothecary. 

Gramma. 

R Sulphuris 3175 R Sulphuris gi ; 

Petrolati 30|00 Petrolati |ji. 

M. M. 

Prescription 61. 
Metric. Apothecary. 

Gramma. 

R Olei cadini 3175 R Olei cadini gi ; 

Petrolati 30|00 Petrolati ^ i. 

M. M. 

These remedies should be used so as to produce a slight rubefaction, 
but not inflammation. 

PEMPHIGUS NEONATORUM. 
In addition to the true pemphigus of adults, the pemphigus which is 
secondary to diseases of a debilitating nature, and the epidemic pemphigus 
infantilis, we at times meet with a form of pemphigus which seems to 
be caused by a parasite of the skin. These cases have been described by 
Blomberg, but they have not yet been fully accepted by dermatologists, 
and it is well to remember that on the delicate skin of infants and young 
children impetigo contagiosa may cause the lesion of pemphigus through 
the activity of the parasite and the great vulnerability of the skin. 

PEMPHIGUS. 

Pemphigus is a disease of a constitutional character, and is represented 
by large blebs and bullae. It occurs at times in infants and children as it 
does in adults, but is very rare. There is a form of pemphigus, however, 



362 PEDIATRICS. 

which I have met with in infants and children in which bullae of various 
sizes appear upon the limbs and trunk, and which is not connected with 
syphilis. It usually occurs in poorly nourished children, and can come 
not only as a disease of itself, but also as one of the sequelae of debilita- 
ting diseases, such as pneumonia, rheumatism, and others. When it is 
secondary to other diseases it represents a condition of malnutrition, and 
in all probability is not connected with the real disease pemphigus. In 
my expedience this class of cases is not especially serious, but merely 
represents a greater or less degree of lack of vitality of the skin. 

This form of pemphigus, in which the efflorescence is secondary to 
other diseases, is not usually seen upon the soles of the feet or in the palms 
of the hands, and this is of considerable aid in distinguishing the disease 
from the bullous form of syphilis. 

Treatment. — There is no especial local treatment which appears to 
benefit this condition of the skin, but it soon disappears when the general 
nutrition of the child has again become normal under appropriate feeding. 

EPIDEMIC PEMPHIGUS INFANTILIS. 

Where pemphigus occurs as an epidemic among infants in foundling 
hospitals it is of a more serious nature, and is accompanied by constitu- 
tional symptoms, represented by fever, sometimes lasting from three to 
six weeks. In these cases it is usually acute, but it may become chronic, 
and last, with intervals of recurrence, for many weeks or months. These 
cases are more apt to be fatal than the other forms. The true epidemic 
form of purulent pemphigus, as it has been called, is almost always fatal, 
and in cases in which it is not secondary to any other disease has a grave 
prognosis. Many of the reported cases of this epidemic form, as well as 
of the other forms of pemphigus, may really be only manifestations of 
the staphylococcus invasion. 

DERMATITIS EXFOLIATIVA NEONATORUM (Bitter's Disease). 

In the year 1878 Ritter gave the first complete description of the dis- 
ease dermatitis exfoliativa neonatorum. Previous to this date cases of this 
affection had been reported, but many of them were regarded as some 
rare or unusual manifestation of pemphigus. Ritter studied and reported 
the cases which he saw at the Foundling Asylum in Prague from 1868 to 
1878. A careful review of Ritter' s original observations of these cases 
has been made by Elliot. The majority of cases were in male infants, 
and the mortality was found to be 48.82 per cent. The disease is very 
rare. It occurred rarely before the end of the first week, and usually 
appeared between the second and the fifth week of life. It was found to 
vary greatly in the intensity of its symptoms. In some cases a dry scaly 
condition of the skin preceded the subsequent lesions, which had ap- 
parently lasted after the physiological desquamation of the epidermis had 
taken place. 



DISEASES OF THE SKIN. 363 

Symptoms. — The first symptom noticeable in these cases was a diffuse 
redness, usually over the lower half of the face about the mouth, some- 
times, however, beginning in some other portion of the body, and at times 
being universal from the beginning. This hyperemia of the skin spread 
rapidly, and in a few days became universal, the extremities, as a rule, 
being the last parts affected. The mucous membrane of the mouth and 
nose was at times affected, and the conjunctivae usually participated in the 
hyperemia. The color of the efflorescence varied from a light to a dark 
purple-red. As the hyperemia extended to new surfaces, those which 
were first affected began to desquamate. This desquamation at times 
gave no evidence of exudation, the epidermis being simply thickened, and 
the loosened epithelium separating easily. At times other lesions appeared, 
such as milia, and sometimes the horny layer of the skin was raised above 
an intensely reddened base, and large, irregularly shaped bullae filled with 
fluid were formed. After the desquamation had taken place the skin re- 
covered its normal condition, occasionally very rapidly, but it remained for 
some time rough and irritable. In the cases in which there was no exu- 
dation a longer time was necessary for the separation and regeneration of 
the epithelium. 

Usually the disease was found to run its course in from seven to ten 
days. Relapses were sometimes observed ten or twelve days after the 
first attack, but were always mild. 

In typical cases the process was unaccompanied by any fever or sys- 
temic disturbances unless some complication existed. The functions were 
normal, and the weight of the infant remained stationary or was even at 
times increased. The fatal cases resulted either from the intensity of the 
attack or from some intercurrent affection or sequela, such as furunculosis. 
The disease is usually recognized as a local septic infection of the skin, 
and it would seem that it should be distinguished from the pemphigus 
which occurs in the early weeks of life. 

I have myself seen but one case in which it seemed that this diagnosis 
of dermatitis exfoliativa could reasonably be made. 

This case was a male infant, who at the fourth or fifth day of its life presented a 
marked condition of erythema neonatorum. After a few days this erythema began to 
desquamate slightly, but somewhat later a pronounced dermatitis appeared and ran its 
course for a week. During the course of the disease there were lesions of various kinds 
represented by a few pustules and bullae, but mostly by an intense erythema. The 
lesions gradually grew less intense, a profuse desquamation took place, and the skin 
then presented a normal appearance. During the course of the disease the infant did 
not show any constitutional symptoms, and gained somewhat in weight. The parents 
were healthy, strong people, with good hygienic surroundings. 

DERMATITIS. 

Dermatitis is an inflammatory affection of the skin, produced by some 
recognized cause. The lesions are, as a rule, fugitive, and with a few ex- 
ceptions are not characterized by an especial and peculiar form of efflo- 



364 PEDIATRICS. 

rescence. The course of the disease, and the recognition of some definite 
exciting cause, enables us to distinguish this condition from others which 
resemble it. 

Clinically the group may be divided into a dermatitis traumatica, derma- 
titis venenata, dermatitis calorica, and dermatitis medicamentosa. 

Dermatitis Traumatica. — Dermatitis traumatica is the term applied 
to the local reaction which takes place in the skin, following some trauma, 
either slight or severe, such as may result from pressure, friction, or 
direct blow T s. The lesions vary from • a simple, temporary erythema to 
deep and extensive ulcers, as in certain bed-sores. 

Dermatitis Venenata. — Dermatitis venenata is the name applied to 
those dermal lesions which are caused by the external application or con- 
tact of irritating substances. The inflammatory condition may be due to 
simple mechanical irritation, such as is sometimes caused by the lodgement 
in the skin of small particles of matter ; or it may be due to a poison, 
arising either from emanation of a poisonous volatile principle or from 
actual contact. Ivy poisoning is one of the most common and important 
examples of this class of affections. It is caused by contact with the 
leaves of the rhus toxicodendron. The cases are most common in the 
autumn, probably owing to the fact that people are tempted to gather 
the leaves because of their brilliant coloring at this season of the year. 
There is some difference of opinion as to the volatility of the poisonous 
active principle. Rhus venenata, or poisonous oak, is another common 
cause of ivy poisoning. 

Some of the more important irritants which may produce a dermatitis 
venenata are chrysarobin, an effective remedy in psoriasis, preparations of 
carbolic acid, turpentine, iodine, mercury, and sinapis. There are sixty or 
more drugs (White) cited as more or less frequent causes of a dermatitis. 
Knowing the great delicacy of an infant's skin, we cannot be too cautious 
in prescribing ointments and applications, or in seeking for the cause of a 
dermatitis in some article which is of common use perhaps, but at times 
an undoubted source of irritation to the skin. 

Symptoms of Ivy Poisoning. — The eruption appears generally within a 
day or two after exposure, with redness, oedema, and papules, which pass 
rapidly to the stage of vesicles, which may become pustular from a second- 
ary infection. The course of the disease is from two to six weeks. The 
face, hands, and genitals are especially liable to be the seat of the disease, 
the extension to other parts of the body taking place by means of the 
hands. 

Diagnosis. — The lesions of ivy poisoning resemble those of an acute 
eczema. In making the diagnosis especial attention should be paid to a 
history of exposure to ivy, the time of year, the asymmetry in the dis- 
tribution of the lesions, and the history of previous attacks, and especial 
susceptibility will often aid in the exclusion of other similar conditions, es- 
pecially eczema. 



DISEASES OF THE SKIN. 365 

Treatment. — There is no specific remedy. The treatment is the same 
as in an acute eczema, except that it is well to begin by washing the skin 
thoroughly with soap and water. Prescription 66, page 370, maybe used 
as a wash, and some simple ointment, as Prescription 68, page 372, may 
be applied. 

Dermatitis Calorica. — Dermatitis calorica is a form of dermal inflam- 
mation produced by the milder degrees of heat. The action of the sun's 
rays is the simplest and most common type met with in children. The 
lesions vary from a simple erythema to vesicles and bullae, depending 
upon the intensity of the heat, the duration of exposure, and the suscep- 
tibility of the skin in an individual case. Diminution of heat may pro- 
duce lesions the character and course of which are very similar to those 
which result from an excess of heat. Chilblaiyis are a common example 
of the result of a diminution of heat. They occur chiefly in children 
with feeble circulation who wet or chill their feet, and suddenly heat 
them. In such instances the skin is red, soft, and boggy. The boggy 
areas may break down and form indolent ulcers, which are difficult to 
cure. 

Treatment. — The treatment of these cases of dermatitis calorica is the 
application of some simple lotion, as in Prescription 63, page 367, or of 
an ointment, as in Prescription 68, page 372. 

Dermatitis Medicamentosa. — Dermatitis medicamentosa is a general 
term including a great variety of lesions produced by the action of certain 
drugs administered internally. Arsenic may produce an efflorescence of a 
very complex character which may be erythematous, papular, urticarial, 
bullous, pustular, and even hemorrhagic. It may also give rise to a herpes 
zoster, as a result of certain changes in the nerve-endings. Belladonna 
often produces an efflorescence of an erythematous character resembling 
closely that which occurs in scarlet fever. The iodides are especially likely 
to cause an efflorescence of acne. The bromides often cause lesions of a 
papular or pustular character. Both the bromides and iodides occasion- 
ally cause lesions of a most unusual character. Chloral, digitalis, opium, 
quinine, the salicylates, and many of the recent new remedies sometimes 
cause an efflorescence. The erythematous, urticarial, and papular efflo- 
rescences which are seen at times after the administration of antitoxin will 
be more fully described under diphtheria. 

Treatment. — The treatment consists in discovering and discontinuing 
the drug the use of which is causing the irritation of the skin. 

SUDAMINA. 

Sudamina is a non-inflammatory condition of the skin caused by occlu- 
sion of the ducts of the sweat-glands. The lesion is represented by 
minute pearl-like vesicles occurring on the skin in crops, and is not apt to 
appear in febrile conditions. The disease is of no significance and requires 
no treatment. 



366 PEDIATRICS. 



ERYTHEMA. 



Erythema plays an important part in the diseases of infants and young 
children. Although it is one of the most common and readily diagnosti- 
cated diseases of the skin which occur in early life, yet at times it is quite 
difficult to differentiate it from other diseases, owing to the variety of its 
forms. It may be divided into two broad classes : (1) the congestive form,, 
or erythema simplex, which is caused by traumatism and by various drugs r 
and is also symptomatic of the acute exanthemata ; (2) the inflammatory 
form, erythema multiforme, which may affect any part of the body and 
either small or large surfaces. It has, however, a predilection for the 
backs of the hands and of the feet. Its lesions may be represented by 
maculae, or in the process of its evolution these macular may develop into 
maculo-papules, vesico-papules, papules, vesicles, and even bullse. The 
lesions vary in size. The color varies from bright red to purplish red, 
and is sometimes very vivid. The delicate texture of the skin of young, 
subjects is more likely to show variations in the color and the form of its 
lesions than is the fully developed and stronger skin of the adult. 

Erythema Simplex. — Symptoms. — The symptoms of the congestive 
form are varied, and they do not accompany each manifestation of the 
disease with any especial regularity. The slightest local irritation, whether 
from parasites or trauma of any kind, changes in temperature, reflex irri- 
tation from the close connection between the digestive organs and the? 
skin, and many other reflex manifestations, may produce the disease. 

Erythema Multiforme. — Symptoms. — In erythema multiforme there 
may be pains in the joints simulating rheumatism, malaise, slight fever, 
nausea, coated tongue, loss of appetite, and a swollen, tender skin. These 
more marked symptoms are, however, often absent, and the lesions of an 
erythema multiforme commonly appear on the skin of young subjects; 
without any special general symptoms accompanying them. It is better 
in nursery practice not to endeavor to classify this protean disease under- 
special names which have been handed down from time immemorial in 
the text-books, and which have no particular significance. They have been 
used indefinitely by physicians, and the same form of lesion is sometimes 
called by one name and sometimes by another. 

Treatment. — The treatment of all forms of erythema is practically the 
same. It consists chiefly in the application of a simple powder of oxide 
of zinc and starch, and of a lotion consisting of either lime-water or rose- 
water in which calamine and oxide of zinc are suspended. 



Prescription 62. 
Metric. Apothecary. 

Gramma. 

R Zinci oxidi 715 R Zinci oxidi gii :. 

Amyli tritici 60|0 Amyli tritici J iL 

M. M. 

S. — For external application. 



DISEASES OF THE SKIN. 367 



Metric. 
R Zinci oxidi, 


Pre 
Gran 

. . . . aa 7 


SCRIPTION 63. 

Apothecary. 
ima. 

R Zinci oxidi, 

5 Calamine praeparatae 

Aquae calcis 

M. 


...aa gii; 
E viii 


Aquae calcis 

M. 


240 



S. — For external application. 

ERYTHEMA INTERTRIGO. 

This is a congestive form of erythema. It is represented in Plate III., 
A, opposite page 84. This form of erythema is that which occurs in 
infants in the folds of the groin, neck, and axillae. The lesion has already 
been described under erythema simplex. Napkins soaked with urine and 
allowed to remain for some time without being changed are a frequent 
cause of this condition. 

The treatment is to keep the skin clean and dry by the application of 
a simple powder. No water should be used on the parts affected, but in 
its place equal parts of lime-water and water can be used for washing. 
Applications of black wash are often efficient. 

In the more severe forms of this disease, in which the erythematous 
condition has become eczematous, and where the skin in the folds of the 
groins, of the neck, or of the axillae shows fissures and the moist con- 
dition represented by eczema madidans, I have found an application of 
boracic acid powder efficacious. 

ERYTHEMA NODOSUM. 
Another form of erythema, called erythema nodosum, is a disease 
which is closely allied to erythema multiforme. The general character- 
istics and symptoms of erythema nodosum are well represented in the 
following case : 

A little girl, five years old, was perfectly well until two days before she came under 
observation. At that time she began to have loss of appetite, fever, and malaise, fol- 
lowed by pain in both her legs. Following these general symptoms an efflorescence 
appeared in various places on her legs. It was found above and below the knees, but 
mostly over the tibiae and extending down as far as the ankles. These lesions were from 
1.2 to 2.5 cm. {I to 1 inch) in diameter, and were of a somewhat irregular elliptical 
outline. They were of an erythematous type and had a delicate pink color. The skin 
over the lesions was hot in comparison with the unaffected portions of the skin around 
them. The lesions were tender on pressure, and their tissues were somewhat indurated, 
so that the feeling was that of a hard, raised swelling. 

The disease is self-limited, but is irregular in its course. It usually 
disappears in about two weeks. Its cause is not known. The treatment 
is simply palliative. 

ERYTHEMA IJRTICATTJM— URTICARIA. 
Nettie-Rash, Hives. — The term urticaria has been applied to an efflo- 
rescence characterized, as a rule, by wheals, which appear suddenly and 
disappear quickly. It is accompanied by intense itching and burning, and 



368 PEDIATRICS. 

may show itself on any part of the skin, in lesions either small or large 
in number. 

It is commonly caused by irritation of the gastro-enteric tract. The 
disease may end in two or three days, but usually lasts for some weeks, 
and may become chronic ; it is essentially, however, an acute affection. 

If the lesion has been severe there may be slight desquamation, but 
this is rare. Sometimes there may be only one attack ; again there may 
be relapses, and in some forms and in certain skins it may occur from 
year to year. 

When seeking for the cause of an outbreak of urticaria it is necessary 
to investigate carefully as to whether there has been an error in diet. In 
children some simple article of food may cause an urticaria to appear, 
just as in some adults the disease occurs from an idiosyncrasy which pro- 
hibits them from eating oysters, lobsters, strawberries, or certain other 
articles of diet. Again, in some individuals, certain drugs, such as chloral, 
bromide of potash, chlorate of potash, and belladonna, may cause the 
dermal lesions of urticaria. The wheals of urticaria frequently occur as 
a symptom in the course of various diseases, such as scabies, or may be 
caused by the bites of insects. 

Treatment. — The treatment should be directed first to the removal of 
the cause of the dermal irritation. When this cause has been removed 
the dermal lesions will, as a rule, disappear, unless still further irritation 
has been produced by scratching the lesion or by its being too severely 
treated by the physician. 

The diet should be milk for a time, and experiments should be made 
with different articles of food to see which one may cause this especial 
form of irritation. The bowels should be carefully regulated. The local 
applications consist of remedies to relieve the itching and burning, in the 
wearing of unirritating clothing and soft linen next the skin, and in a 
powder of starch and zinc, made as described on page 366, frequently 
applied to the lesions at intervals during the day. When the itching is 
extreme, anti-pruritic lotions and ointments should be used, as in the 
following prescriptions : 

Prescription 64. 

Metric. Apothecary. 
Gramma. 

R Pulv. calaminse 7 5 R Pulv. calamine 5 ii ; 

Aq. calcis 240 Aq. calcis g viii ; 

Acidi carbolici 1 87 Acidi carbolici 3 ss. 

M. M. 

When this lotion is not sufficient to allay the irritation and when the 
burning is extreme, the following ointment can be applied : 

Prescription 65. 
Metric. Apothecary. 

Gramma. 

R Menthol 016 R Menthol gr. x ; 

Adipis 30|0 Adipis £i. 

M. M. 



DISEASES OF THE SKIN. 369 

ECZEMA. 

Eczema is a disease of the skin which plays a much greater role in 
infancy and early childhood than in any other period of life. It is often 
very difficult to cure. Even in the milder forms of the disease we should 
be cautious about giving too favorable a prognosis at first, for the disease 
may extend and involve new areas of skin. 

Pathology. — The pathological changes which occur have been desig- 
nated by certain descriptive names, such as eczema erythematosus^ generally 
secondary to other lesions ; eczema papillosum, which may be a terminal or 
merely a secondary stage of the process ; eczema vesiculosum, which is 
never primary, but is preceded by a papular stage, and may end as such 
or pass on to the more advanced lesions ; eczema madidans, or " weeping 
eczema,' 1 in which the vesicles form large blisters containing sero-purulent 
or sero-hemorrhagic contents which exude and form crusts ; eczema pustu- 
losum, which may begin as a primary lesion or develop secondarily to the 
vesicular or madidans stage ; and, finally, eczema squamosum, which is never 
primary, but represents the final stage of the pathological process in which 
the epidermal scales are thrown off, leaving exposed a dry, itchy, reddened 
skin. After resolution, cicatrices rarely occur, unless from severe secondary 
changes. 

Symptoms. — Clinically the disease may be divided into the acute form, 
characterized by a sudden onset, short course, and frequent recurrence of 
any of the pathological conditions just mentioned ; and by the chronic 
form, which represents the more characteristic lesions of cell infiltration 
and thickening of the skin, scaling, fissures, and ulcers. The disease may 
begin as an acute or as a chronic process, starting as an erythema or as 
isolated and grouped papules, vesicles or pustules, either singly, simul- 
taneously, or in succession, resulting in redness, oozing, scaling, crusting, 
and infiltration. The intense itching and burning, without tenderness, are 
the important and characteristic points serving to distinguish the condition 
from a dermatitis. The disease may be divided into two types, regional or 
local eczema and universal eczema. 

Regional Eczema. — The most common form of regional eczema oc- 
curring in infants and young children is localized on the face, and com- 
monly extends to the neck. This form is especially distinctive of infancy, 
and is frequently very intractable. No one form of treatment or kind of 
application benefits every case, but one remedy after another may have 
to be tried. As the infant grows older this form of eczema passes away 
of itself and is not apt to return. 

Many instances of local eczema produced by some irritation at or near 
the place affected, or perhaps in an entirely different part of the body, are 
met with in children. This is usually called reflex eczema, an example of 
which may be found in the irritation of the scalp, such as occurs from 
pediculi, from which a local reflex eczema may develop on the back of the 
neck. 

24 



370 PEDIATRICS. 

Other varieties of regional eczema are limited to the eyes, giving rise to 
swelling, pustules, furuncles, and conjunctivitis, a condition which may 
easily be mistaken for erysipelas, but shows no tenderness and itches 
badly. The ears, genitals, legs, feet, and hands may all be the site of 
eczematous lesions. 

Universal Eczema. — Attacks of universal eczema may occur in chil- 
dren as they do in adults, and are often very intractable. The lesions are 
essentially the same as in regional eczema, but differ in that they are more 
universally distributed. 

Treatment. — The importance of the treatment of eczema does not de- 
pend so much on any particular ointment or drug as on the method of 
applying the remedy. The principal indication is to keep the child quiet 
and the skin free from the irritation of scratching, thus allowing it to 
recover its vitality. At times it is necessary to strap the child on its back 
in bed and to have a nurse in constant attendance until the more irritable 
stage of the disease has passed off. Scratching the lesions even for a few 
moments may retard the recovery for many weeks. 

If necessary in the early hours drugs of a soothing nature may be 
given to prevent undue nervous symptoms. The nurse should be gentle, 
and should endeavor continually to divert the child's mind. The treat- 
ment consists, then, first in allaying the itching by local applications, and 
of so covering the part affected that scratching is impossible. It is often 
necessary to pin the sleeves of the dress to the napkin in order to control 
the hands. The discomfort from the restraint will soon pass away, and 
the method of treatment is not cruel. Certain general precautions should 
be observed. Heat and excess of cold should be avoided, and the' cloth- 
ing should be thin and as non-irritating as possible. The physical condition 
of the child should be carefully investigated in regard to the urine, blood, 
bowels, appetite, and nutrition, and appropriate symptomatic treatment 
should be given. 

Drugs. — Drugs may be administered as washes, powders, and oint- 
ments, but never as tinctures, in the acute forms of eczema. Water should 
never be used in the treatment of acute eczema. The list of drugs is long, 
and only a few of the more important ones need be mentioned. A sim- 
ple powder of starch and zinc oxide, such as is given on page 366, will be 
found most useful on moist surfaces. In all acute cases, and as an anti- 
pruritic, the following prescription will be found of value. 

Prescription 66. 

Metric. Apothecary. 
Gramma. 

R Zinci oxidi 15 00 R Zinci oxidi ^ ss ; 

G-lycerini 3 75 Glycerini g i ; 

Acid, carbol 1 88 Acidi carbolici (xtals ) 3 ss ; 

Aq. calcis q.s. ad 240 00 Aquae calcjs q.s. ad ^ viii. 

M. M. 

Calamine may be used in the above prescription in place of the oxide 
of zinc, as in Prescription 64 on page 368, and it is often desirable to add 



DISEASES OF THE SKIN. 



371 



60 c.c. (2 ounces) of camphor- water to replace an equal quantity of lime- 
water. An ointment of sulphur and oxide of zinc, 1.88 gramme (J drachm) 
of each to 30 grammes (1 ounce) of vaseline, is very useful in eczema of 
the scalp. 



Fig. 97. 




Eczema capitis. 



In the treatment of the dry, scaling, infiltrated form of chronic eczema, 
when there are no excoriations or acute lesions, the following prescription 
of White's may be used. 



Metric. 



Prescription 67. 
Gramma. 



Apothecary. 



R Sapo viridis, 

Alcohol aa 60 

Filter and add 

Olei cadini 15-30 

M. 



R Sapo viridis, 

Alcohol aa ^ ij ; 

Filter and add 

Olei cadini ^ ss-j. 

M. 



Fig. 97 represents a case of eczema of the scalp and face which illus- 
trates the disease very well. 



They consisted of papules, pus- 



Fig. 98. 



The lesions were confined to the head and face, 
tules, crusts, some excoriated patches caused by- 
scratching, and a thick, rather oedematous con- 
dition of the skin, especially around the lips, 
nose, and eyes. The hair was cut off, and 
various lesions were found on the scalp ; in cer- 
tain parts of the scalp a reddened moist con- 
dition, called eczema rubrum, was found. 



The treatment was as follows : the crusts 
and the thickened tissue of the face and scalp 
were first softened by means of a poultice. After 
the larger crusts had been removed, a mask, as 
shown in Fig. 98, was applied to the face and 
scalp. The inner surface of this mask was thickly spread with the following ointment : 




Method of treating eczema capitis. 



372 PEDIATRICS. 

Prescription 68. 
Metric. Apothecary. 



Gramma. 
R Unguenti zinci oxidi, 

Lanolini aa 30 



R Unguenti zinci oxidi, 
00 Lanolini aa £ - 



An interesting complication of universal eczema which may at times 
arise is illustrated in the following case : 

A girl came to the hospital to be treated for torticollis. The head was drawn to 
the left side and she could not straighten it. This condition had lasted for many 
months. 

On examining the child I found that she had the usual universal eczema of a chronic 
type affecting the head, face, and extremities. On examining the neck I found a num- 
ber of enlarged tender glands. These enlarged glands were evidently caused by reflex 
irritation from the eczema, and were the cause of the torticollis. 

She was treated with the zinc oxide ointment (Prescription 68) and the usual 
bandage and mask, and in a short time, although the eczema was not entirely cured, 
the irritation in connection with it had been so much lessened that the glands of the 
neck gradually subsided and disappeared, and the child was able to hold her head 
straight. 

We are often asked whether the eczema of infants is contagious. I have 
seen instances where the nurse who was taking care of a case of eczema 
developed the disease on her hands. The lesions were, however, ap- 
parently caused by washing the infant's napkins, as her hands were cured 
by local treatment, and the subsequent use of rubber gloves while washing 
the napkins prevented her from again contracting the disease. Cases of 
this kind give rise to the idea that eczema is contagious, but the proba- 
bility is that they are simply cases of artificial dermatitis caused by irri- 
tating substances of various kinds, and that there is no especial germ 
which causes eczema. We can, therefore, say that the disease is not con- 
tagious, and that simple cleanliness and protection of the hands by means 
of rubber gloves are all that is necessary to prevent the disease being 
contracted. 

PSORIASIS. 

Nothing is known of the real cause of psoriasis. So far as we can 
ascertain, it is not dependent on any micro-organism. When the disease 
is well developed the diagnosis is very simple, and its lesions correspond, 
as a rule, to those which are commonly met with in the adult. It begins 
with small papules, which almost immediately become covered with scales. 
These scales have a pearly white color, and on removing them we find a 
bleeding surface, showing that they are more closely connected with the 
corium than is the case in other diseases in which desquamation takes 
place, such as dermatitis or scarlet fever. 

The efflorescence of psoriasis is general, and is, as a rule, marked on 
the elbows and knees, for in these places the lesions coalesce and the 
scales are especially thick. 



DISEASES OF THE SKIN. 373 

I have noticed in the psoriasis of children that the type of the disease 
is often so mild that we can scarcely believe we are dealing with the same 
affection that we are accustomed to see in the adult. In some cases a 
few lesions scattered here and there, especially on the back over the scap- 
ulae, will be all that represent the disease, and are easily cured, even dis- 
appearing of themselves in a few months. Besides affecting the trunk 
and extremities, the efflorescence may occur on the scalp, especially along 
the edge of the hair on the forehead, but the disease is not very common 
on the face. Psoriasis is apt to recur even at intervals of years, so that 
we cannot say that it can be absolutely cured, although at times it may 
disappear under treatment and never return. 

Treatment. — The treatment of psoriasis in children should be milder 
in form than that employed in treating the adult. In the above case an 
ointment of chrysarobin applied to the lesions in the evening and washed 
off with soap and water in the morning was used, there being no treat- 
ment during the day. 

Prescription 69. 
Metric. Apothecary 

Gramma. 

R Chrysarobini 0160 R Chrysarobini gr.x ; 

Petrolati 30|00 Petrolati ^i. 

M. M. 

This ointment stains the skin, but not permanently. It should never 
be applied to the face or the scalp, and should be used with great care, as 
it causes on some skins considerable irritation, and at times a severe der- 
matitis. With ordinary caution, however, this need not occur. 

In intractable cases in which this milder form of ointment is not effi- 
cacious, the strength may be increased to 1 or 1.5 grammes (15 or 20 
grains) to the ounce. 

It should be remembered that chrysarobin stains the clothes black in- 
delibly, so that old sheets and night apparel should be used while the 
treatment is being carried out. 

In place of this ointment you can use on especially irritable skins, or 
on the face and scalp, the following prescription of sulphur and tar : 

Prescription 70. 
Metric. Apothecary. 



R Sulphuris 3 

Olei cadini 1 

Adipis 30 



M. M. 



Gramma. 

75 R Sulphuris gi; 

87 Olei cadini 3 ss ; 

00 Adipis g i. 



PRURIGO. 

Prurigo occurs in two forms in infants and children, — (1) prurigo mitis 
infantilis and (2) prurigo fer ox. 

(1) Prurigo Mitis Infantilis. — Prurigo mitis infantilis occurs in infants 
two or three months old, and may last for some years. It is closely allied 



374 PEDIATRICS. 

to papular erythema, but is more chronic and has a greater tendency to 
recur. It is very rare in America. 

Symptoms. — It begins with little nodular infiltrations, especially marked 
on the anterior surface of the extremities, and is accompanied by great 
itching. It may appear on the face. It does not lead to an infiltration of 
the skin or to the formation of pus. 

Treatment. — The treatment consists in remedies to relieve the itching 
and allay the eczema with which it is usually complicated. 

(2) Prurigo Ferox. — Instead of this mild form a more severe type of 
prurigo occurs at times. This latter form is far more serious in its symp- 
toms and in its prognosis, and may continue through life. The disease, 
which is characterized by the same dermal lesion as that just described, is 
progressive from the beginning ; it usually starts on the legs, and the skin 
becomes thicker as it descends. The efflorescence is accompanied by 
enlarged glands, especially in the inguinal region. 

The disease is rare in America, but is common in Germany. 

Its etiology is very obscure, and it is a most intractable chronic 
affection. 

Treatment. — The treatment is palliative. 

For the extreme itching caused by the papules an application of the 
following ointment may be used : 

Prescription 71. 
Metric. Apothecary. 

Gramma. 



R TJnguenti diachyli, 

Petrolei aa 30 



R TJnguenti diachyli, 

00 Petrolei aa g i. 

M. M. 

S. — To be applied on flannel three times a day for ten minutes, and to be followed by 
the application of this ointment : 

Prescription 72. 
Metric. Apothecary. 

Gramma. 
R TJnguenti diachyli, R TJnguenti diachyli, 

Petrolati aa 30|00 Petrolati aa ^ i. 

M. M. 

If there is much infiltration, sapo viridis should be applied at night 
and washed off the next morning. It must, however, be used with 
caution, as it is very irritating. 

HERPES ZOSTER. 

Herpes zoster is a disease which affects both children and adults. The 
cause of the disease has not as yet been determined, but it is a condition 
closely connected with the nerves. 

Symptoms. — The general symptoms of herpes zoster are fever, loss of 
appetite, and pain in some part of the head, trunk, or extremities. The 
pain is always located in the course of certain nerves. In some cases, 
however, the pain and constitutional symptoms are absent. 



DISEASES OF THE SKIN. 375 

One of the characteristics of the efflorescence is that, as a rule, it is 
unilateral. It is extremely rare for the affection to be bilateral and to ex- 
tend around the body. Cases of this kind, however, have occurred, and 
do not seem to be any more severe, except that larger surfaces are affected, 
than where the affection is unilateral. The character of the efflorescence 
is essentially vesicular, and is to be differentiated from varicella, which 
might be accompanied by the same general symptoms and is also essen- 
tially a vesicular disease. The efflorescence of varicella is general, is not 
limited to any special distribution of the nerves, nor is it painful, while the 
efflorescence of herpes zoster is limited to the distribution of a special set 
of nerves. The vesicles become somewhat pustular, and soon crusts are 
formed. 

The disease runs a definite course of about fourteen days, and from 
the beginning is accompanied by considerable pain, although according to 
my observations the pain is not so severe in children as in adults, nor is 
the itching so annoying. 

Diagnosis. — The diagnosis of this disease is very easily made from the 
general symptoms of pain, fever, and malaise, in combination with the 
characteristic efflorescence, and we at once know with what disease we are 
dealing, for no other affection of the skin has so definite a distribution. 

Prognosis. — The disease is usually benign in children, but the case of 
a child four years old who died during an attack of herpes zoster without 
other assignable cause has been reported. 

Treatment. — The treatment is simply palliative. What I am accus- 
tomed to do is to regulate carefully the child's diet, as I would in any 
disease with general constitutional symptoms, and to endeavor by the 
application of lotions to allay the pain. Sometimes merely a simple 
powder, such as the prescription on page 366, is sufficient to allay the 
local symptoms. 

PITYRIASIS. 

Pityriasis is a term that is now, like the word lichen, seldom used 
without an accompanying adjective. There are two recognized forms of 
the affection. 

(1) Pityriasis Rubra is a rare disease in children, characterized by 
hyperemia and fine scales affecting, as a rule, the whole cutaneous sur- 
face. It may be attended with great constitutional disturbance and lead 
to death. Its duration is always uncertain. 

(2) Pityriasis Maculata et Circinata, or Pityriasis, Rosea affects chil- 
dren as well as adults. It appears in the form of small patches of scales 
scattered over the trunk, legs, and arms. These patches either spread 
peripherally or unite to form larger patches while the centre undergoes 
involution ; we thus see a reddish scaling border and a characteristic yel- 
lowish centre. There may or may not be great pruritis accompanying it. 
In Vienna this affection is still regarded as a form of ringworm, a posi- 
tion that cannot, however, be maintained. Its etiology is obscure. It gets 



376 PEDIATRICS. 

well spontaneously in from two to ten weeks, and is best treated by mild, 
soothing, and anti-parasitic applications. 

VERRUCA. 

Verrucse (warts) are circumscribed outgrowths of the papillae of the 
skin with an accompanying increase in the thickness of the epidermic 
layers. They are common in children, especially on the hands, and the 
old view that they are contagious and auto-inoculable has gained many 
adherents of late. They are of various aspects and shapes, and may be 
treated locally, as a rule, with success, although some are quite obstinate. 
The most efficacious method of treatment is to paint each wart with a 
solution of salicylic acid in flexible collodion (Prescription 73). 

Prescription 73. 
Metric. Apothecary. 

Gramma. 

R Acidi salicylici 3,75 R Acidi salicylici gi; 

Collodii 30|00 Collodii £i. 

M. M. 

This is applied with a camel's-hair brush twice a day for three days. 
Then it is soaked off by prolonged bathing in warm water, with the addi- 
tion of pumice soap if there is no inflammation. This will usually remove 
a portion of the wart, and the process should be repeated as long as any 
of the growth is left. 

The treatment with salicylic acid is not always successful, and recourse 
may then be had to glacial acetic acid, or to some other caustic, carefully 
applied ; or the growth may be excised. 

LENTIGO. 

Lentigo (freckles) is a small aggregation of pigment deposited in the 
skin, and is commonly seen in children of ten years and upward, espe- 
cially in those of light complexion. They are usually situated on the face 
and hands, but may occur on the covered portions of the body, a fact that 
led Hebra to regard them as not due to the action of the sun. There can 
be no doubt, however, that the sun is the chief agent in their production. 
Their removal is often difficult and requires the use of strong irritants, 
such as corrosive sublimate. It is rarely advisable to attempt their re- 
moval in young children. 

MELANODERMA LENTIOULAEIS PROGRESSIVA.. 

Melanoderma lenticularis progressiva (Kaposi's disease) is a very rare 
disorder, and is seldom met with in this country. In this affection spots 
of pigment like freckles appear first on the uncovered parts of the body, 
finally extending more or less over the whole cutaneous surface. The 
pigment-spots are the first lesions seen, but later an atrophy of the skin 
and the formation of small angiomata dotted over the surface take place, 



DISEASES OF THE SKIN. 377 

giving the child an extraordinary appearance. The disease is usually 
found in more than one child in the same family, and its etiology is very 
obscure. Malignant tumors with a fatal ending often result from this 
affection. I have had two cases under my observation for four or five 
years. One has lately died, and the autopsy showed no metastases in 
the interal organs, the disease proving purely a local affection of the skin ; 
the other has returned to the hospital in a worse condition than ever 
before. No treatment of any kind, medical or surgical, has had any effect 
on this case. 

LICHEN. 

Many of the affections that were formerly included under the head of 
lichen are now considered by most authorities to belong in other groups, 
notably in that of eczema. A diagnosis of lichen is never made by 
American dermatologists, but lichen planus is a well-marked skin disorder 
which retains a place of its own. It rarely occurs in children, but when 
present it follows about the same course as in adults. It is characterized 
by firm papules of an irregular shape and glistening appearance, of a 
peculiar reddish-blue or violet color, with usually a slight depression in 
the centre. The individual papules may coalesce, so as to form patches 
of greater or less extent, covered with fine scales. It is often accompanied 
by great itching and discomfort. It attacks all parts of the body, showing 
a predilection, however, for the flexor surfaces of the arms and legs. It 
may last for many months, and in the most favorable cases does not dis- 
appear for several weeks. The general health is not usually affected, ex- 
cept by the exhaustion that may be caused by intense itching. It may 
be confounded with a papular syphilide, which it often closely simulates, 
and sometimes it may be mistaken for an eczema. Arsenic is of value in 
chronic cases, and anti-parasitic lotions and ointments, especially those 
containing tar in some form, give relief as external applications. 

ICHTHYOSIS. 

The disease ichthyosis as it occurs in infants and young children does 
not differ in its general pathology from that which is seen in adults. It 
may occur in intra-uterine life, and is then designated foetal ichthyosis. 

The most thorough work which has been done on the ichthyosis of 
infancy and childhood is that of Ballantyne of Edinburgh, who designates 
that form which has occurred in utero and is fully developed at birth as 
(1) foetal ichthyosis, Avhile the form which begins in the early weeks of 
infancy he speaks of as (2) ichthyosis neonatorum. 

(1) Foetal Ichthyosis. — The severity of foetal ichthyosis varies 
greatly. 

(a) Severe Form. — The grave form, according to Ballantyne, is devel- 
oped probably about the fourth month of intra-uterine life, and is charac- 
terized at the time of birth by the existence all over the body of horny epi- 
dermic plates separated from one another by fissures and farrows, associated 



378 PEDIATRICS. 

with deformities of the mouth, nose, eyes, lips, and limbs, and leading 
within a few days or even hours to the death of the infant. As in most 
cases infants with this disease are born alive, fcetal ichthyosis cannot be 
considered to be a cause of intra-uterine death. The disease does not 
seem to affect especially the size and weight of the infant. As a rule, the 
viscera at the post-mortem show nothing abnormal except an unusual de- 
gree of congestion. The microscopic examination shows no extension of 
the keratinizing process on any of the mucous membranes, and the dis- 
ease is an abnormality in the development of the skin, there being an 
excessive proliferation of the layers of the epidermis. 

Symptoms. — In the early hours of life infants with this disease usually 
cry loudly and continuously, but sometimes the cry is feeble and often 
very peculiar. The respiration is usually impeded by the blocking of the 
nostrils with epidermal masses. Suction is rendered difficult or altogether 
impossible by the presence of ichthyotic plates around the mouth. They, 
are, however, usually able to swallow readily. As a rule, nothing abnor- 
mal is found in connection with the urine or the faeces. Insomnia is a 
marked symptom. 

These infants have a very repulsive appearance, and there is a cadav- 
eric odor arising from the abnormal condition of the skin. This ichthy- 
otic condition of the skin is usually universal, but is most evident upon 
the face. The mouth is ordinarily kept open by the contraction of the 
surrounding parts, and from its angles radiate fissures which simulate the 
rhagades of syphilis. The lips are thick and everted, so as to form an 
irregular entrance to the gaping buccal cavity. The chin is receding. 
The nose can scarcely be seen, it is covered so thickly with the epidermal 
plates around the nostrils. There is usually ectropion of both eyelids, 
but sometimes only of the upper one, the orbits seeming to be occupied 
by fleshy tumors. If, however, we separate the swollen eyelids, the 
normal eyeball is found to lie beneath. The external ear seems to have 
disappeared almost entirely. 

In contradistinction to the opinion formerly held that fcetal ichthyosis 
was a general seborrhcea, it is now generally supposed to be connected 
with the disease as it occurs in the adult. 

Prognosis. — The prognosis of the disease is almost always unfavor- 
able. 

Treatment. — The treatment should be active and directed towards 
softening the epidermic scales by means of warm oil inunctions. 

(b) Mild Form. — Besides the grave form of fcetal ichthyosis, there is a 
much milder form of the disease. It develops during intra-uterine life, 
and shows a continuous layer of a substance resembling collodion extend- 
ing over the whole body and falling off in small flakes resembling pieces 
of tissue-paper. These general appearances are sometimes accompanied 
by ectropion and eclabium. The disease is not, as a rule, fatal, and often 
terminates in complete or partial recovery. There have not been any 



DISEASES OF THE SKIN. 379 

instances, so far as I know, of an infant being born dead with this form 
of ichthyosis. 

Treatment. — The treatment of this second form should be by continual 
stimulation of the child's general strength and by great care of the skin. 

(2) Ichthyosis Neonatorum. — Ichthyosis in the new-born infant, in 
whom at birth there was no sign of the disease, may occur. It presents 
the same appearances as the milder form of foetal ichthyosis and the 
ichthyosis of the older child and the adult. 

This is the common form of ichthyosis, which occurs at all ages. It 
begins for the most part in the early months of life, is essentially chronic, 
and is very intractable to treatment. 

Treatment. — It should be treated by the administration of a warm 
bath once daily, followed by an inunction with glycerite of starch. 

SCLERODERMA. 

Scleroderma is a disease which at times occurs in children as it does 
in adults. It consists of an induration of the skin either in bands or in 
patches, or is diffuse, having a board-like hardness, so that the skin can- 
not be raised by the fingers and feels as though it were tacked down. 
Scleroderma affects the motions of the joints, and when it occurs about 
the chest and throat may interfere with respiration. It appears to be a 
condensation of the fibrous layers of the skin, so that the bundles of 
connective-tissue fibres are packed closely together and are increased in 
number. It is chronic, is not very dangerous, and is best treated by 
massage and lubricating applications. 

ACUTE CIRCUMSCRIBED OR ANGIO-NEUROTTC CEDEMA. 

A lesion of the skin which has been termed acute circumscribed oedema 
is represented by the sudden appearance of circumscribed swellings of 
certain parts of the body, varying in intensity and size in different locali- 
ties. It is closely allied to urticaria, and was formerly described under 
the name of giant urticaria. We do not know much about either its cause 
or its pathology. I have sometimes met with it in children in whom it 
was evidently of reflex origin, depending, probably, upon irritation in 
various parts of the body, such as the mouth, the genitals, and the gastro- 
enteric tract, sometimes, probably, of toxic origin. 

It is not dangerous, may occur at any age, and its treatment is simply 
symptomatic. 

The following cases illustrate the disease : 

A little boy, two and one-half years old, had had diarrhoea during the summer, 
and had been left in rather a weak, debilitated condition. He had for some weeks 
been pale, fretful, and constipated. His appetite had been capricious, and he had not 
cared to take any food but milk. When he was nineteen months old an egg had been 
given to him, which he vomited, and later a slight swelling of both eyes had occurred, 
lasting for a day or two. 



380 PEDIATRICS. 

When I saw the child the history that was given me was that in the morning he 
had eaten an egg. Soon after he became rather dull and cross, but did not vomii. 
A slight swelling of both eyes was then noticed, and later, when I saw him, the right 
eye was very much swollen, so that the conjunctiva was corrugated, and the tissues 
of the eyelids and of the cheek under the eye were so swollen that the eye itself could 
be examined only with the greatest difficulty. Each time that the child had eaten an 
egg this swelling occurred in about fifteen minutes. In the course of a few hours the 
swelling passed off, and did not return. An examination of the urine showed nothing 
abnormal. 

Another instance of this kind occurred in a boy of three years, in whom the 
peripheral irritation was evidently dependent upon a tight and irritating prepuce. In 
this case sudden (Edematous swellings of the fingers and backs of the hands would 
occur at irregular intervals, lasting for a few hours, and would then entirely disappear. 
These manifestations continued until the child was circumcised, since which time 
the symptoms have not returned. In this case, also, the urine was found to be 
normal. 



DIVISION VIII. 

SPECIFIC INFECTIOUS DISEASES. 



The number of infectious diseases which are supposed to be caused 
by some specific infection is so rapidly increasing that at present no defi- 
nite classification of them can be made. In like manner our knowledge 
of the specific organism which in an individual case produces the disease 
is so continually advancing that we can only make a provisional division 
into somewhat arbitrary groups of the diseases which we speak of as 
infectious. Thus, in certain diseases, tuberculosis, cerebro-spinal menin- 
gitis, typhoid fever, diphtheria, epidemic influenza, malaria, tetanus neo- 
natorum, erysipelas, certain forms of ileo-colitis, and cholera asiatica, the 
micro-organism is known ; while in others, such as epidemic parotitis, 
pertussis, syphilis, and acute articular rheumatism, which are evidently 
just as infectious, the specific micro-organism has not yet been discovered. 
Again, there are certain infectious diseases which have usually been classed 
in a group by themselves on account of the marked similarity which they 
present in their general characteristics. This group, as a whole, has been 
designated as the exanthemata, and comprises scarlet fever, measles, 
rubella, variola, and varicella. 

TUBERCULOSIS. 

Tuberculosis is an infectious disease due to the invasion of the tissues 
by the tubercle bacillus. 

General Etiology. — Intra-uterine infection of the fetus by a tu- 
berculous mother from direct infection may occur. Infection by the 
father from the mother, or from the ovum of the mother has not been 
proved. In the great majority of cases the child is infected after birth. 
This infection may be by direct inoculation from the mouth, as in the 
Jewish rite of circumcision, or, as is the most common means of trans- 
mission, from the inhalation of the bacilli contained in dry sputum. A 
less common mode of invasion is that from uncooked food. The bacillus 
tuberculosis may be present in cow's milk, and very exceptionally in the 
milk of human beings. 

The question of the relation of bovine tuberculosis to human tuber- 
culosis and the danger of infecting man from the milk of tuberculous cows 

381 



382 PEDIATRICS. 

have received renewed attention of late. The researches of several in- 
vestigators, particularly those of Smith, seem to show that the bovine 
tubercle bacillus is more virulent for certain species of animals than the 
human tubercle bacillus. Whether the two organisms are distinct or 
whether the differences which have been noticed between them are simply 
modifications brought about by the adaptations of the bovine bacillus to 
the different conditions in the human body are points still to be deter- 
mined. The weight of evidence, however, in regard to infection from 
milk is quite sufficient to justify the following practical conclusions : 

(1) That tuberculosis in many cases may be transmitted to animals 
either through the ingestion or inoculation of the milk of cows that are 
tuberculous. (2) That the milk of such cows may be infectious even 
when there is no tubercular disease of the udders. (3) That, therefore, 
the milk of certain tuberculous cows contains living, virulent tubercle 
bacilli. (4) That, whereas, from the nature of the case, it is impossible 
by direct experimentation to prove that the milk of certain tuberculous 
cows is pathogenic for man, nevertheless the clinical evidence of compe- 
tent observers, strengthened by the results of animal experimentation, 
makes it practically certain that tuberculosis may be produced in man by 
the ingestion of the milk of infected cows. (5) That it is, therefore, of 
the utmost importance that the milk supply, especially that which is used 
as food for infants and young children, shall be from an absolutely relia- 
ble source. 

The infection of food by flies carrying the bacilli from one point to 
another is possible. Direct infection may also take place by the skin, and 
in these cases it produces a local lesion. The bacilli may pass through a 
mucous membrane without infecting it, and may be taken up by the 
lymphatics and carried to the lymph-nodes where their progress is usually 
arrested for some time. 

Tuberculosis is a very prevalent affection in early life. It is very rare 
in the new-born and infrequent in the first three months of life. After 
this age the number of cases increases rapidly, and the disease is very 
common in the latter part of the first year and in the second year, grad- 
ually growing less common as puberty is approached. The presence of 
tuberculosis in children is very much underestimated. In two hundred 
and twenty autopsies of diphtheria, tubercular lesions were found usually 
in the lungs, and sometimes in the lymph-nodes of the mesentery, in six- 
teen cases. The disease is very much more common in young children 
than has been supposed, and it may exist before there are any symptoms 
at ail. 

The bacilli find entrance into the body in various ways. The chief 
mode of entrance is probably through the respiratory tract. The organ- 
isms may also enter through the alimentary canal or by means of the 
skin. As a rule, where the bacillus finds an entrance into the tissue it 
produces at that point the characteristic lesion of the disease. In other 



SPECIFIC INFECTIOUS DISEASES. 383 

cases close examination fails to reveal any lesions at the point of entry, 
although this does not preclude the possibility that the lesions may be 
present. It is probable that the bacilli enter into the circulation in small 
numbers, and are conveyed to various tissues of the body, as the bones or 
joints, and the disease may appear as a primary infection in organs remote 
from the point of entrance. Frequently the bacilli, without apparently 
producing any lesions at the point of entry, enter into the lymphatics and 
are carried to the lymphatic glands in which the disease first appears. 
Having gained an entry into the tissue the disease always extends by 
means of the bacilli, which are carried from place to place through the 
natural canals or channels of the lymphatics which are in proximity to 
the diseased focus, or by means of the blood. In all cases of tuberculosis 
it is probable that there is some infection of the blood. A few bacilli 
find their way into the blood, and are deposited by it in those organs in 
which the circulation is most favorable for their arrest. We have an ex- 
ample of this in the almost constant miliary tuberculosis of the liver when 
the infection is elsewhere. At times the bacilli find their way into the 
blood in large numbers. This general infection of the blood is due either 
to a tuberculosis of the blood-vessels or to a tuberculosis of the thoracic 
duct. The bacilli, entering into the blood in large numbers, are conveyed 
into the different organs of the body and give rise to the condition known 
as acute miliary tuberculosis. 

Predisposition. — The predisposition to tuberculosis may be hereditary 
or acquired. It is hereditary in the sense that the individual inherits 
tissues which are more or less receptive to, and which provide a favorable 
material for the development of the tubercle bacillus. In diseases result- 
ing in a great reduction of the vitality, and in certain acute infectious dis- 
eases, such as measles, pertussis, and epidemic influenza, a tuberculous 
predisposition seems to be acquired. Bad food and poor hygienic surround- 
ings, especially absence of sunlight in the crowded tenement districts of 
large cities, render the tissues more vulnerable to the tubercle bacillus. 
In like manner any debilitating disease, by lowering the resistance of the 
tissues, acts as a predisposing cause. Repeated attacks of catarrhal in- 
flammation of the mucous membrane of the nose, throat, bronchi, or 
intestinal tract render these parts more vulnerable. Infectious diseases, 
especially those in which the respiratory organs are affected, predispose 
to tuberculosis. In these cases it would seem that the bacilli have been 
latent in the lymph-nodes surrounding the bronchi until, under the irrita- 
tion of the new disease, they become active again. 

General Pathology. — Tuberculosis is characterized by the production 
of tissue in which there is proliferation and an inflammatory exudation. 
The proliferation of tissue leads to the formation of epithelioid and giant 
cells. The inflammatory exudation may be serous, fibrinous, or purulent. 
Usually in the tubercular lesions there is both the tissue proliferation and 
the inflammatory exudation. The proliferation of tissue occurs in the 



384 PEDIATRICS. 

form of small nodules which are called miliary tubercles. The tubercu- 
lous tissue is further characterized by a form of necrosis, and the necrotic 
tissue has a tendency to soften and break down. These miliary tubercles 
often coalesce so as to form what is known as conglomerate tubercles, in 
which the process of necrosis is especially marked, giving rise to the 
" cheesy" nodules so characteristic of the disease. Certain degenerative 
changes are common in tuberculosis. Thus fatty deg-eneration frequently 
occurs from the diminished oxygenation due to the destruction of lung 
tissue. Again, amyloid degeneration is common in those forms of tuber- 
culosis which run a chronic course, and in which there is marked de- 
struction and suppuration of tissue. The lesions of tuberculosis are very 
numerous, and in the child do not differ materially from those which are 
found in the adult. The ordinary chronic tubercular lesions met with in 
the adult are seldom seen in children. 

The younger the child the more likely is tuberculosis to be chiefly 
located in the lung. As the child grows older the meninges are commonly 
affected, and later the peritoneum, intestines, and joints. During the first 
two years of life the lesions of meningeal tuberculosis are rare in com- 
parison with the period beginning with the third year, and the pulmonary 
lesions usually result fatally before there has been extensive invasion of 
the intestines and joints. As the child passes into its third year the 
marked pulmonary lesions lessen in frequency and the meningeal forms 
become more common. Later the joints become a prominent nidus for 
meningeal infection, and in older children the peritoneum, intestines, and 
mesenteric lymph-nodes show, more commonly, marked lesions. At all 
ages, however, there are usually found pulmonary lesions more or less 
marked whenever infection has taken place with the tubercle bacillus. 

Prophylaxis. — In considering the question of prophylaxis in tubercu- 
losis, special attention should be paid to what has already been said of the 
modes of invasion and of predisposition. In all cases in which there is 
a family history of tuberculosis the child should, if possible, be surrounded 
with unusual precautions ; a change from a severe to a mild climate, 
especial care of even mild catarrhal affections of the mucous membranes, 
much fresh air, but dry, warm, fresh air, protection from inhalation of dust, 
rooms with a sunny exposure, and freedom from living in the house with 
a tuberculous individual, are precautions especially to be observed. Ex- 
posure to the diseases which have been mentioned as most likely to be 
followed by tuberculosis should be carefully avoided. Tuberculous nurses 
should never be allowed to take care of children, tuberculous individuals 
should not be allowed to kiss children, and the sputum from a tuberculous 
individual should be destroyed at once before it has become dried. A 
tuberculous mother or wet-nurse should not be allowed to nurse an infant. 
The animals which provide milk should, at stated intervals, be carefully 
tested with tuberculin, and when the source of the milk is not known or 
doubtful, the milk should be heated to 68.3° C. (155° F.) for half an hour. 



SPECIFIC INFECTIOUS DISEASES. 385 

The following case, seen by me in consultation with Dr. W. L. 
Richardson and Dr. H. P. Jacques, illustrates the importance of prophy- 
laxis : 

A boy. five years old. died of tubercular meningitis. The autopsy showed exten- 
sive tubercular lesions of the meninges with enlarged bronchial lymph-glands and 
cheesy nodules at the apices of both lungs. The child up to the time of the attack 
had always been perfectly well. There was no history of tuberculosis in the family. 
There were several other children, none of whom had ever shown any symptoms con- 
nected with tuberculosis. This boy, at the age of fourteen months, was placed in the 
charge of a nurse, who remained with him until he was four and a half years old. 
Just before leaving the child, she was brought into especially close connection with 
him while his parents were away for some weeks. The child was very fond of her, 
insisted on being in her lap a great deal, kissed her on the mouth, slept in her bed, 
and kept her in the nursery with him continuously. The nurse, while taking care of 
the child, developed tuberculosis of the lungs and subsequently died of this disease. 
Other cases of this kind have been known to occur. 

General Symptomatology. — After a variable period of loss of weight 
and general health, which especially occurs in cases in which acute mili- 
ary tuberculosis is secondary to measles or to pertussis, the infant 
begins to have an irregular type of fever, cough, and general symptoms, 
such as diarrhoea, capricious appetite, anaemia, and change of tempera- 
ment. In some cases the disease appears with a sudden rise of tempera- 
ture and advances very rapidly, but it is often of a subacute type, and 
frequently, unless the tuberculosis markedly affects some organ, such as 
the lung, the symptoms are very obscure, death finally taking place from 
exhaustion or from the development of some localized condition, such 
as tubercular meningitis or some acute pulmonary complication, broncho- 
pneumonia being especially common. 

General Diagnosis. — From what has been said concerning the symp- 
toms of tuberculosis, it is evident that when no localized tubercular 
lesions are found, the diagnosis, excepting by supposition, is not pos- 
sible. It is probable, however, that when more is known regarding 
the use of tuberculin in infants and in young children, this method of 
diagnosis will be more frequently used, and will prove of value by pro- 
viding us with a safe method for detecting an incipient tuberculosis, 
and thus aid us in preventing the development of later and more serious 
lesions. 

Tuberculin Test. — The technique of the tuberculin test as described 
by Koch is as follows : One c.c. of tuberculin added to 999 c.c. of 
distilled water equals -oVo- and 1 c.c. of this solution equals 1 milli- 
gramme. The dose of this solution for an infant or young child is from 
J to 1 c.c. In using this test a record of the child's temperature must 
first be kept every two hours for twenty-four hours. If it is then found 
that the temperature is irregular or high the test is not of much value. 
If, however, the temperature is regular and not over 38.3° C. (101° F.), 

25 



386 PEDIATRICS. 

the test can be used, and has been found in my experience at the In- 
fants 1 Hospital to be of considerable value. After the part of the skin 
to be injected has been thoroughly washed first with soap and water, 
and then with alcohol, and the hands of the operator and the syringe 
disinfected, from J to 1 c.c. of the solution are injected into the arm or 
leg. If the child is not tubercular no symptoms will be noticed. If 
it is tubercular the temperature will rise in from eight to twenty-four 
hours after the injection, and will fall again within about twenty-four 
hours. During the period of reaction there may be a certain amount of 
malaise, but in my experience there is little or no danger of serious 
results. 

General Prognosis. — The prognosis of tuberculosis in early life Is 
almost invariably bad. Even when the bacilli have been encapsulated 
they are liable at any time to become active. 

General Treatment. — Of especial importance in the treatment of 
children with tuberculosis in any form is the general hygiene, fresh, dry 
air, a warm, dry climate, and plenty of sunshine. The treatment by 
drugs is very unsatisfactory and usually without good results. In some 
cases cod-liver oil seems to be of temporary benefit. Cream is useful 
and should be given when cod-liver oil is not well borne or is especially 
distasteful. A general diet adapted to the age and condition of the 
especial child, and the treatment of symptoms which arise when special 
organs are involved, are the only rational procedures. Tuberculin has 
not as yet been proved to be sufficiently valuable as a therapeutic agent 
to be accepted by the medical profession in general. 

The following case illustrates how extremely latent and masked may 
be the symptoms of tuberculosis 

An infant, seven months old. was in the Infants 1 Hospital from October until 
December. During this time it became extremely emaciated, diarrhoea occurred from 
time to time, and there was an irregular and varying temperature,, never especially high. 
It had a purulent discharge from the right ear, and a serous discharge from the left ear. 
There were no other symptoms and no abnormal physical signs. It failed rapidly and 
died. The autopsy showed miliary tuberculosis of the pleura, spleen, kidney, and 
liver, chronic tuberculosis of the bronchial lymph-glands and of the lung, and broncho- 
pneumonia. 

GENERAL TUBERCULOSIS. — General tuberculosis in early life 
may be acute or chronic. It is now believed that in every case there is a 
tubercular focus, usually in a gland or in the lung, from which the general 
infection has emanated. The early symptoms of a general tubercular in- 
vasion vary much and are often obscure. As a rule, they appear before 
the symptoms of local tuberculosis of an especial organ, and are repre- 
sented by irregular temperature, anaemia, and a general lowering of the 
nutrition and vitality. 



SPECIFIC INFECTIOUS DISEASES. 387 

ACUTE MILIARY TUBERCULOSIS. 
The term acute is somewhat misleading in speaking of miliary tuber- 
culosis, since this form of general tuberculosis varies greatly in the rapidity 
of its invasion and in the intensity of its symptoms, according to the 
rapidity with which the bacilli gain an entrance to the circulation, and in 
proportion to the susceptibility of the individual to their virulence. Some 
of these cases are extremely acute, while others are markedly chronic. 
There are certain organs of the body which are rarely affected. This 
must be attributed to the fact that the organs in question do not offer 
favorable conditions for the development of the bacillus. Thus, it is ex- 
tremely common for the bronchial lymph-nodes and the lungs to be 
affected, while it is rare for the stomach or the genito-urinary organs to 
be markedly involved. Especially noticeable in comparison with those 
acute cases which occur usually in somewhat older children with pro- 
nounced symptoms, and representing the form which is called the 
typhoidcd type of the disease, is the clinical picture represented by those 
cases which occur in early infancy, and which are markedly subacute 
rather than acute, simulating closely infantile atrophy. 

Pathology. — The disease is characterized by the formation of nodules, 
varying in size and character, in the different organs and tissues of the 
body. As a rule, the nodules (miliary tubercles) are larger and not so 
characteristic as in the adult. As compared with the adult, they vary 
somewhat in their distribution. They are much more numerous and 
larger in the liver in the case of the child than they are in the adult. 
The condition is produced by the entry of the tubercle bacillus in large 
numbers into the blood. They may enter the blood through a blood- 
vessel, or by means of infection of the thoracic duct following infection by 
the lymph-nodes. It is not probable that they multiply directly in the 
circulating blood, but they may multiply in the blood-vessels of organs in 
which the blood-stream is comparatively inactive, as in the liver. 

(1) Acute Miliary Tuberculosis Simulating- Typhoid Fever. — Symp- 
toms. — The symptoms of this type of the disease are very indefinite. There 
is rapidly progressive emaciation. The temperature is irregular, and fluctu- 
ates from 37.2° or 37.7° C. to 40° or 40.5° C. (99° or 100° F. to 104° 
or 105° F.), or even higher. The respirations are often accelerated beyond 
what can be explained by the fever, and physical signs are markedly absent 
in the lungs. The pulse is rapid. Certain cases of this class simulate typhoid 
fever by presenting symptoms of apathy, headache, slightly enlarged spleen, 
and tympanites. In making the differential diagnosis from typhoid fever it 
is well to take into consideration the family history in regard to tubercu- 
losis, and also whether the child has been living where typhoid was preva- 
lent. Although no leucocytosis is present in either disease, yet it has been 
held that while in typhoid there is a relative increase in the small mononu- 
clear cells, there is in tuberculosis a relative decrease. In other respects 



388 PEDIATRICS. 

the blood simply shows the characteristics of a secondary anaemia. The 
Widal reaction is absent in tuberculosis. The tubercle bacillus may or 
may not be present in the sputum. In some cases the bacilli of typhoid 
and tuberculosis have been found in the urine. The tuberculin test is 
seldom of value in these cases, as the fever is continuous and usually 
sufficiently high to prevent the characteristic rise of temperature from 
being perceptible. The less regular temperature, the rapid respirations, 
and the absence of rose spots are significant of tuberculosis. Finally, 
in most cases the tendency of typhoid fever is gradually to recover, while 
tuberculosis shows progressive emaciation and the development of new 
symptoms according as other organs are involved. In some cases malaria 
may simulate tuberculosis, but the presence of the plasmodium as deter- 
mined by a blood examination and the response to the treatment with 
quinine serve to separate this disease from tuberculosis. 

Prognosis. — The course of this type of the disease is short and the 
result invariably fatal. 

(2) Acute Miliary Tuberculosis Simulating- Infantile Atrophy. — 
Symptoms. — I have frequently had patients brought into the Infants' Hospital 
in whom it was impossible to differentiate in the beginning, and perhaps 
for weeks, what eventually proved to be miliary tuberculosis. The symp- 
toms in these cases are simply progressive emaciation, with occasionally a 
temperature moderately raised, but in no way differing from what is fre- 
quently found in the atrophic condition in which a slight disturbance of 
digestion may cause a similar rise in temperature. These tubercular 
cases simply die of exhaustion, with no physical signs developing during 
life, the disease being completely masked and only recognized at the 
autopsy. In some cases, however, after a variable period, physical signs 
can be detected in the lungs, the temperature rises more and more, and 
there may be cough and accelerated respirations. In these cases, also, 
there are at times diarrhoea and general gastro-enteric disturbance, but 
these conditions depend entirely on the reduced condition of the infant 
and not upon tubercular lesions of the intestine. The temperature in 
these cases varies from 37.2° to 38.8° C. (99° to 102° F.). It must be 
remembered that infants with simple infantile atrophy at times develop 
non-tubercular broncho-pneumonia and die of it, so that a diagnosis 
made by finding physical signs in the lungs in those cases which simulate 
infantile atrophy is not conclusive, as the signs do not necessarily prove 
that tuberculosis is present. On the other hand, acute miliary tubercu- 
losis of the lung usually presents no physical signs whatever, so that the 
differential diagnosis between many cases of acute miliary tuberculosis 
and infantile atrophy must be held in abeyance, and, unless the tuber- 
culin test can be used, cannot be made except at the autopsy. 
Prognosis. — The prognosis is fatal. 

Treatment. — The general treatment of acute miliary tuberculosis is 
essentially symptomatic and by the use of stimulants. When the disease 



SPECIFIC INFECTIOUS DISEASES. 



389 



simulates typhoid fever, the treatment should be such as is described in 
that disease, on the supposition that it may turn out to be typhoid. When 
it simulates infantile atrophy, however, the CHAET 4. 

treatment should be the same as in that 
disease, and is essentially dietetic. 

The following case was one of acute 
miliary tuberculosis : 



An infant, one and a half years old, was 
brought to the Infants' Hospital to be treated for 
an attack of bronchitis. On entrance it was much 
emaciated and failed rapidly. No marked signs 
beyond a subacute bronchitis were found. There 
was at times a slight cough. The temperature was 
moderately raised and of an irregular type. The 
thorax and legs, especially the buttocks, showed 
numerous subcutaneous abscesses, and there were 
also a few on the head. Five days before the in- 
fant died the temperature rose as represented on 
Chart 4. The post-mortem examination showed 
that there was chronic tuberculosis of the bron- 
chial glands, with acute miliary tuberculosis of the 
pleura, lungs, spleen, kidneys, liver, and meninges. 





Days of Disease 




IP. 














c. 


107° 
106 
105 
104 


RI E 


M E 


M E 


M E 


M E 


M E 


41.6° 
41.1° 
40.5° 
40.0° 




































-s: 


103 
102° 
101 
100 
99° 

NORMAL 
TEMP. 

98 
97 

o 

96 

o 

95 












Q 


39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36. l c 

35.5° 

35.0° 








V 


^ 










\ 










) 








<s 














u 




— 













































Acute miliary tuberculosis. 



CHRONIC GENERAL TUBERCULOSIS. 

In addition to the lesions which characterize acute miliary tuberculosis, 
a chronic general form of tuberculosis occurs in certain cases. The symp- 
toms are more marked than in the acute form, and usually are so closely 
connected with the bronchial lymph-nodes and the lungs that it is more 
easily diagnosticated. This chronic general tuberculosis is one of the 
more common forms of tuberculosis in children. 

LOCALIZED TUBERCULOSIS.— Although tuberculosis may by a 
general infection invade all the tissues, thus constituting the general tuber- 
culosis just described, it is apt to be so pronounced in certain parts, and 
so much more common in some than in others, that these localized forms 
can best be described separately. An instance illustrating this is given in 
the lymph-nodes of the neck in children where the node is very com- 
monly found to be tuberculous, and yet in many cases no trace of a gen- 
eral tuberculosis can be found elsewhere. 



TUBERCULOSIS OF THE LYMPH-NODES. 

Tuberculosis of the lymph-nodes is an exceedingly common form of 
tuberculosis in children. In all forms of tuberculosis the lymph-nodes are 
affected. The tubercle bacilli come in very close relation with the lymph 
spaces and ducts and are carried by them into the lymph-nodes belonging 
to the part. There are also cases of tuberculosis of the lymph-nodes in 



390 PEDIATRICS. 

which the disease appears to be primary in these parts. Such cases 
are found in the lymph-nodes of the neck, of the axillae, and of the 
mesentery. 

Tuberculosis of the lymph-nodes appears in two forms : (1) the nodes 
are enlarged and contain the tubercular tissue in the form of miliary 
tubercle, which by their increase and coalescence can form large caseous 
areas ; (2) the nodes are also enlarged in the form of diffuse tubercles, 
leading to the caseation of large areas, in fact, the entire node may be 
converted in consequence of this caseation of the diffuse tubercular tis- 
sue into a large caseous mass. The caseous tissue of the nodes may 
soften, break down, and even suppurate, leading to the formation of tuber- 
cular abscesses. The bacilli having entered at some point can be carried 
from the point of entrance by the lymph-streams into the nearest lymphat- 
ics and lymph-nodes, without the production of local lesions. In gen- 
eral, the lymph-nodes play an important part by preventing the tubercle 
bacilli from entering into the blood, and the disease from extending fur- 
ther. It is very interesting to note that the lymph-nodes can soften and 
break down in this way and be discharged, and that no further infection 
need follow. 

Tuberculosis of the Cervical Lymph-Nodes (Scrofula). — The most 
important of the lymph-nodes affected in tuberculosis are the lymph- 
nodes of the neck. Invasion of the cervical lymph-nodes may occur 
primarily by infection from the throat. When this invasion occurs in 
connection with tuberculosis of the lungs the infection of the cervical 
nodes is probably primary to the pulmonary lesions. The cervical 
lymph-nodes are more commonly affected by the tubercle bacillus in the 
early period of childhood than in infancy, in which the infection of the 
bronchial nodes are so frequently met with. When the term scrofula 
was in more general use, tuberculosis of the cervical lymph-nodes was 
considered as one of its most frequent manifestations ; now the term can 
be dropped entirely. 

Symptoms and Diagnosis. — In cases in which the cervical lymph-nodes 
begin to enlarge in a marked tuberculosis, as of the lung, the symptoms 
are those of a slow process extending over months, with a tendency to 
suppuration. 

The diagnosis in these secondary cases is made by eliminating the 
causes of glandular enlargement which could produce a similar hyper- 
plasia by reflex action, or which could be produced by some other organ- 
ism. The diagnosis, however, is chiefly made by the tubercular history 
of the case, as in the majority of cases the nodes under these circum- 
stances are tubercular. 

Primary tuberculosis of the cervical lymph-nodes is to be distinguished 
from other forms of infection by its slow progress, by its greater tendency 
to suppuration, and also by the fact that the suppuration as a whole takes 
place later than the simple form. The enlarged cervical nodes due to syphi- 



SPECIFIC INFECTIOUS DISEASES. 391 

lis, Hodgkin's disease, or malignant growths should be differentiated from 
tuberculosis of the cervical lymph-nodes, as described in these diseases. 

Prognosis. — The prognosis of tuberculosis of the cervical lymph-nodes 
is good, the exception being for the child to develop tubercular disease 
elsewhere. The prognosis when the tuberculosis is secondary to tuber- 
culosis elsewhere varies according to the tubercular lesions from which it 
originates. 

Treatment. — When the tubercular disease has extended to other 
organs there is seldom much benefit to be derived from the treatment of 
these nodes. Although it is conceded that general tuberculosis following 
tubercular cervical adenitis is exceedingly rare, yet there have been 

Fig. 99. 




Chronic pulmonary tuberculosis, with involvement of the cervical lymph-nodes. 

cases reported in which such infection has taken place, and the glands 
should be removed unless they have grown smaller in a number of 
months, at any rate if they show signs of softening. A change of climate 
is indicated, and if the child has a tubercular inheritance especial care 
should be taken to keep the naso-pharynx and throat in a healthy condi- 
tion. Adenoid growths and enlarged tonsils should be removed. Any 
lesion of the face and head which may cause irritation should be treated, 
as, by their reflex action, they may cause increased activity of the tubercle 
bacilli. 

Medicines, except for special conditions, such as anaemia, are useless. 



392 PEDIATRICS. 

External applications of an irritating nature are contra-indicated. Pre- 
venting the head from rolling from side to side, and thus pressing on the 
inflamed glands, can sometimes be accomplished by various mechanical 
devices in the shape of collars. The operative treatment includes not 
only the removal of the gland, but the removal of it at such a time that 
the smallest scar will be left, as in many cases following a suppuration of 
these glands unsightly scars are left which disfigure the child for life. 
These cases should, therefore, be placed in the hands of a skilful surgeon. 

Fig. 99 represents a child with tuberculosis of the cervical lymph- 
nodes in a case of marked chronic tuberculosis of the lungs. 

Tuberculosis of the Bronchial Lymph-Nodes. — Of all the lymph- 
nodes in the body, the bronchial lymph-nodes are probably the most fre- 
quently infected, due to the fact that the primary focus of infection is so 
commonly found in the lungs, and, as the lymph flows from the lung 
towards the nodes, the nodes may be infected in this way by the lung. 
Thus, the bronchial lymph-nodes protect the body from general infection, 
but do not protect the lungs, and such tubercular lymph-nodes can be- 
come, moreover, a starting-point for further extension of the disease after 
the primary lesions by which the lymph-nodes themselves became infected 
have been recovered from. 

Tuberculosis of the bronchial lymph-nodes, if it is extensive, may in- 
volve the pneumogastric nerve. The nodes may possibly suppurate into 
a bronchus, and the infection can in this way also extend into the lungs. 

Symptoms. — Various symptoms may arise from the breaking down and 
ulceration of the bronchial lymph-nodes, or by their pressure they may 
cause irritation of the neighboring parts. Thus, an annoying cough may 
be produced by local irritation. Loeb has reported cases in which the 
previous symptoms had been only cough, and in which an attack of suffo- 
cation caused death. Adelbert and Vogel have reported cases in which 
ulceration originating from these points has resulted in death. The 
physical signs are indefinite and unreliable, and we must depend upon 
the general symptoms of spasmodic cough and dyspnoea, without an ade- 
quate explanation of these symptoms being found elsewhere. 

Tuberculosis of the Mesenteric Lymph-Nodes. — Tuberculosis of 
the mesenteric lymph-nodes may be seen without any evidence of tuber- 
culosis elsewhere in the body, or it may be found in connection with 
intestinal tuberculosis. In all cases the infection is by means of the 
intestine, although there may be no lesions at the point of invasion. 

When the nodes can be reached or definitely localized, they should 
be removed, even if laparotomy has to be performed ; for there is always 
danger not only of their breaking down and becoming a source of general 
tubercular infection, but also a peritonitis may arise suddenly at any time 
from acute inflammation of the peritoneum originating from a disintegrated 
node and ending fatally in perhaps a few days. A case of this kind is 
described on page 843. 



SPECIFIC INFECTIOUS DISEASES. 393 

TUBERCULOSIS OF THE LARYNX AND TRACHEA. 

Tuberculosis of the larynx and trachea is very rare in infants and rare 
in young children. When it is present it is invariably secondary to tuber- 
culosis of the lungs. The symptoms are the same as those of non-tubercu- 
lar disease of these organs, and the diagnosis can only be made definitely 
by finding the tubercle bacillus in the sputum. 

Treatment. — The treatment does not differ from that of the non- 
tubercular cases. 

TUBERCULOSIS OF THE LUNGS. — The tubercle bacillus may 
be brought to the lungs by means of the blood or by the respiratory 
passages, the latter, according to Northrup, being the most frequent in 
children, the bacillus entering with the inspired air and lodging in the 
mucous lining of the bronchi or in the alveoli. When carried by the 
blood they are generally scattered throughout the tissue and give rise to 
miliary tubercles. In some cases the infection may arise from the throat 
with or without the production of a local lesion, the bacilli being carried 
through the lymph-nodes into the blood and from the right side of the 
heart to the lung. Rarely a very few bacilli may be brought to the lungs 
by the blood. They may affect only a certain definite portion of the 
lung and give rise to lesions which are scarcely distinguishable from the 
lesions produced by the entry of the bacilli through the respiratory 
passages. Tuberculosis of the lungs may occur in three forms : (1) acute 
miliary tuberculosis, (2) the more diffuse tubercular pneumonia, and (3) 
chronic tuberculosis of the lungs. 

Ordinarily the distinction made between acute miliary tuberculosis 
and tubercular pneumonia lies in the preponderance of the exudative 
lesions in the latter. In the lungs of children there is a much greater 
tendency to exudation than in adults, and even in acute miliary tubercu- 
losis the essential proliferative changes are, as a rule, accompanied by 
exudation. There is a further difference between children and adults in 
that the chronic forms of tuberculosis which are accompanied by exces- 
sive destruction of tissue, with inflammation leading to a formation of 
fibrous tissue, and producing the condition known as fibroiditis, are seen 
to a much less degree in children than in adults. 

(1) ACUTE MILIARY TUBERCULOSIS OF THE LUNG. 

Acute miliary tuberculosis of the lung has been described on page 
387 as a part of acute general miliary tuberculosis. It presents no other 
symptoms, when the acute process is limited to the lung, than those which 
have been already mentioned as occurring in the acute general miliary 
tuberculosis. There may, however, be a formation of miliary tubercles 
in the lung in combination with other forms of tuberculosis of this organ, 
the formation of tubercles being a more chronic process than in the acute 
disease. 



394 PEDIATRICS. 

(2) ACUTE TUBERCULAR BRONCHO-PNEUMONIA. 

Etiology. — Acute tubercular broncho-pneumonia is common in chil- 
dren from the sixth month to the fifth year, a large proportion of the 
cases, however, occurring after the second year. It may begin in the 
lungs, or may be secondary to any other of the lesions of general tubercu- 
losis, or it may follow any non-tubercular lesion of the lungs, such as 
bronchitis or broncho-pneumonia. It is common in children who have 
been debilitated by previous illness, and occurs especially after measles, 
pertussis, scarlet fever, and diphtheria, being most frequent in the first 
two. It may, however, develop in perfectly healthy, well-nourished chil- 
dren, and, as Osier has expressed it, may be a terminal process in cases 
in which a local tubercular disease exists in other parts, such as the skin, 
bones, lymph-nodes, or the uro-genital tract. 

Pathology. — The infection extends by means of the bronchi, and the 
lesions extend through the bronchi and the alveoli into the surrounding 
tissue. This is a true pneumonia. There is an exudation into the alveoli 
of the lungs, which consists chiefly of fibrin and leucocytes. In addition 
to this, there are numbers of large cells, which probably arise from pro- 
liferation of the epithelium lining the alveoli. Both the exudative and 
the proliferative cells undergo caseation, and the tubercular pneumonia 
may occur in the form of discreet nodules similar to ordinary forms of 
broncho-pneumonia, or in the form of larger areas, which may arise either 
by confluence of the smaller foci or by the simultaneous affection of a 
large area of the tissue. 

As in the other forms of broncho-pneumonia, the initial lesion is a 
bronchitis and peri-bronchitis, the distinguishing tubercular features being 
caseation and necrosis of the consolidation with the presence of the 
tubercle bacilli. The accompanying phenomena of atelectasis and emphy- 
sema occur as they do in non-tubercular broncho-pneumonia. In some 
cases the non-tubercular broncho-pneumonia precedes the tubercular dis- 
ease, this occurring particularly after measles, scarlet fever, diphtheria, 
and pertussis. When the tubercular broncho-pneumonia follows the non- 
tubercular form, in addition to the lesions of the latter disease, there are 
found true tubercular processes, such as peri-bronchial nodules, tubercular 
infiltration, and caseous areas. 

It is rare for the tubercular process in children to begin at the apices 
of the lungs and gradually extend downward, as is common in adults. 
When this occurs it is usually in the later years of childhood, when the 
conditions are beginning to approximate those of later life. 

Tubercular broncho-pneumonia may be acute or chronic, but it is 
rarely very chronic. It may occur in very small foci apparently following 
the bronchi, or it may invade a much larger area and even an entire lobe 
of the lung. 

Symptoms. — The symptoms of acute tubercular broncho-pneumonia 



SPECIFIC INFECTIOUS DISEASES. 395 

are very similar to those of non-tubercular broncho-pneumonia. Ac- 
cording to Osier, in most cases the onset of the disease simulates that of 
the ordinary non-tubercular broncho-pneumonia so closely that a differ- 
ential diagnosis between the two diseases cannot be made until after 
death, and even then the post-mortem appearances may not be those 
distinctive of tubercular disease, and the pathological diagnosis can be 
determined only by finding the tubercle bacillus. Children may be at- 
tacked with cough, a heightened temperature, and the physical signs of 
broncho-pneumonia. These signs, as would naturally be expected, are 
usually found in the back and lower portion of the lung rather than at 
the apices, as in adults, on account of the usual nidus of the tubercular 
lesions, — namely, the bronchial lymph-nodes. In some cases the onset 
of the disease is not so acute, and its course not so rapid. The child 
emaciates and has only a moderate temperature, but later the develop- 
ment of such symptoms as sweating, chills, and hectic fever, together with 
the signs of softening and breaking down of the lung-tissue, leads us to 
suspect that we are dealing with tuberculosis of the lung. 

Diagnosis. — The diagnosis, as a rule, is to be made by taking into 
consideration the family history of the child, as the tissues of children 
whose parents are tubercular show an especial liability to infection by 
the tubercle bacillus. Careful investigation should be made as to whether 
the child has been exposed to tuberculosis in any form ; whether it has 
itself shown signs of any localized form of tuberculosis ; and especially 
whether it has recently had an attack of measles or pertussis. The 
physical signs are in no way characteristic, as they may not only be simi- 
lar to those of the non-tubercular form of broncho-pneumonia, but also 
Ave must remember that the various local conditions of chronic interstitial 
pneumonia and persistent broncho-pneumonia, although simulating tuber- 
cular disease, may in children be non-tubercular, Continuous fever of a 
rather high grade in comparison with the non-tubercular pneumonia, the 
greater intensity of the anaemia, and emaciation mark the tubercular inva- 
sion. When the symptoms develop insidiously, especially following measles 
and pertussis, instead of beginning during the course of these diseases, 
tuberculosis is probable. It must, however, be remembered that simple 
non-tubercular processes may last for many months, and the children 
finally recover. The diagnosis can be made positively only in those cases 
in which a specimen of the sputum can be obtained and examined for the 
tubercle bacillus. 

Prognosis. — The prognosis is invariably unfavorable. 

Treatment. — The treatment of tubercular broncho-pneumonia is the 
same as that of the non-tubercular forms (page 701). 

(3) CHRONIC TUBERCULOSIS OF THE LUNGS. 
Chronic Diffuse Tuberculosis. — Chronic tuberculosis of the lungs as 
it is ordinarily met with in adults is rarely seen in young children. 



396 PEDIATRICS. 

During the first three months of life tubercular disease of any form is 
very rare, but in the latter part of the first year it becomes very common. 
The tubercular lesions which are found in the lungs in later life also occur 
in early life. Although cavities are not so commonly found in young 
children as in adults, it is not so much that they do not exist, but because 
they are located at the root and central portions of the lung, and are, 
therefore, more difficult to detect on physical examination. It has been 
noticed that large cavities at the apex of the lung are rare in early life, 
but become more common as the child grows older. Tubercular disease 
of the lung is very irregular in the extension of its lesions in young chil- 
dren. Much more advanced lesions are usually found at the post-mortem 
examination than are detected during life. The primary lesion of chronic 
tuberculosis of the lungs is commonly a tubercular broncho-pneumonia. 

Chronic Localized Tuberculosis. — In this form, from a single tuber- 
cular focus, there is an extension of the disease by continuity. The 
bacilli find their way into the surrounding lung-tissue by means of the 
lymphatics, or by means of the infection of the adjoining alveoli. Nodules 
varying in size may be produced. In this form of localized tuberculosis 
there seems to be a high resistance of the tissue to the tubercle bacillus, 
and there is not the same tendency to an extension of the infection as 
in the other forms. After undergoing caseation the tissues seldom remain 
in this condition, for the caseous material tends to soften, and is discharged 
by means of the bronchi, or it may be partly absorbed, leaving a cavity 
in its place. 

Symptoms. — The symptoms of chronic tuberculosis of the lungs differ 
but little in the child from those seen in the adult, and are marked by 
the same irregularities in their course. This is due to the varied forms of 
the lesions. In young infants the symptoms are so often obscure and the 
physical signs of the serious pathological conditions which exist in the 
lungs are so frequently masked that the diagnosis is apt to be very doubt- 
ful. There is often a history of tuberculosis in the parents. The more 
common symptoms of chronic tuberculosis of the lungs are gradual loss 
in weight, strength, and appetite, irregular and moderate hectic fever, and 
sweating. The physical signs are slowly increasing dulness in certain 
areas of the lung, especially in the back, accompanied by rales and the 
other signs of solidification. Later in the disease the characteristic signs 
of cavities may develop. Cough is usually present, although it is sometimes 
so slight in the beginning as not to be especially noticed by the parents. 
Haemoptysis is rare in infants and in young children, but may be present 
in older children as they approach the age of puberty. As the disease 
progresses there is dyspnoea, usually of a moderate grade, with cyanosis, 
but in some cases considerable destruction may have taken place in the 
lung-tissue without the presence of any especial dyspnoea. 

The course of chronic tuberculosis of the lungs is rather more rapid 
in children than in adults, and it is seldom that the long-protracted course 



SPECIFIC INFECTIOUS DISEASES. 397 

of the disease so frequent in adults is met with in children. Sometimes, 
however, the child improves in its general health and may live for many 
years. In these cases the terminal phalanges of the fingers may become 
clubbed, and there is usually dyspnoea on exertion. 

Diagnosis. — The diagnosis is to be made from chronic empyema and 
from chronic non-tubercular broncho-pneumonia. The former disease 
can be readily eliminated by making an exploratory aspiration, but the 
latter can often be distinguished only by means of a bacteriological exam- 
ination. In older children, from whom a specimen of the sputum can 
be obtained, the diagnosis is readily made by the detection of the tubercle 
bacillus. In younger children, in whom expectoration does not take 
place, the diagnosis is much more difficult, but if the children are care- 
fully watched it is often possible to obtain a specimen of the sputum if 
the child happens to vomit, in which case particles of sputum may be 
coughed up with the vomitus and can be separated from it and examined. 

Prognosis. — The prognosis of chronic tuberculosis of the lungs when 
the symptoms are at all advanced is very unfavorable, but the post-mortem 
examinations of so many individuals who have died of non-tubercular 
diseases show the presence of old tubercular lesions which have ap- 
parently ceased to be of grave import, that we must acknowledge that it 
is possible for many cases to survive the invasion of the disease. 

Treatment. — The treatment of chronic tuberculosis of the lungs is 
essentially climatic, and the children should be removed at once, if possi- 
ble, from a climate Avhere the altitude is low and the atmosphere damp 
and subject to great variations. Too high altitudes are also to be avoided. 
When the child cannot be removed to a more favorable locality, strict 
attention to its general hygiene and to its food will in some cases be fol- 
lowed by an apparent arrest of the tubercular process. 

The treatment of chronic pulmonary tuberculosis especially calls for 
fresh air and sunshine. The food should be given at regular intervals five 
or six times in the twenty-four hours, and should be adapted to the di- 
gestion of the especial case. There are no drugs which are of much 
value in this disease. Cod-liver oil is commonly given, and in many 
cases seems to be tolerated by the stomach, and to be even agreeable to 
the child. In my experience, however, pasteurized twenty-four per cent 
cream with five per cent, lime-water is equally efficacious, and to most 
children much less distasteful. When the appetite is poor a nerve 
tonic, such as tincture of nux vomica, is often found to be beneficial, and 
when there is considerable anaemia the tartrate of iron and potash is 
indicated. 

The following case (Fig. 100, p. 398) illustrates chronic tuberculosis of 
the lung following an acute infectious disease : 

A girl, eight years old, had a history of tuberculosis in her family. She had an 
attack of pertussis when she was six years old, and some months later an attack of 
measles. Following the attack of measles she began to have headache, cough, and 



398 



PEDIATRICS. 



expectoration. She complained of pain in her chest and abdomen, and of chilly sen- 
sations, and progressively lost in weight and strength. A physical examination 

Pig. 100. 





Chronic tuberculosis of the lung. Female, 8 years old. 
showed the skin to be dry and harsh and the heart normal. The left lung in front 
appeared to be normal. Behind over a small area at the upper part of the lung there 

CHAKT 5. 





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Chronic tuberculosis of the lung. 



were dulness, broncho-vesicular breathing, and some fine moist rales. Over the right 
upper lobe in front and behind there was dulness, and the expiration was prolonged 



SPECIFIC INFECTIOUS DISEASES. 399 

and high-pitched. Over the dull region were heard medium and fine moist rales. 
The borders of the areas of dulness are indicated by black lines, and the rales by 
black spots. The area of cardiac dulness. the lower part of the sternum, and the 
lower border of the ribs are indicated by dark lines, and the edge of the liver, which 
seemed to be somewhat enlarged, by an interrupted line. 

The chart shows the irregular temperature which is commonly seen in cases of 
chronic tuberculosis of the lungs, and is of the remittent type. 

The child was gradually failing and the signs of disorganization of the lung were 
slowly progressing. 

TUBERCULOSIS OF THE PLEURA. 

Tuberculosis of the pleura is a common affection in general tubercu- 
losis and in tuberculosis of the lungs. The symptoms and treatment do 
not differ from non-tubercular pleuritis, but hemorrhagic exudations are 
rare in early childhood. 

TUBERCULOSIS OP THE GASTRO-ENTERIC TRACT.— Tuber- 
culosis of the gastro-enteric tract occurs most often in connection with 
and following tuberculosis of the lungs, the infection being due to the 
swallowing of sputum containing the tubercle bacillus. In rare cases the 
bacilli may find their entrance in milk or through food. Tuberculosis of 
the oesophagus, stomach, and duodenum is exceedingly rare. The oesoph- 
agus probably escapes infection owing to the fact that the sputum con- 
taining the bacilli remains for so short a time in contact with its walls, 
which are also protected by their many layers of epithelium. The 
stomach probably owes its protection to the presence of the gastric juice. 

TUBERCULAR rLEO-COLITIS. 

Etiology. — Tuberculosis of the intestine is not so common in infancy 
as in older children. In the latter, however, it is met with quite com- 
monly, especially in the middle period of childhood. The disease may be 
primary in the intestine, but this is very rare. At the Boston Children's 
Hospital I have had one case in which the tubercular lesions were confined 
to the intestine and to the mesenteric nodes. In this case Professor Coun- 
cilman considered that the evidence was in favor of the intestinal tubercle 
antedating the tubercle of the nodes. In the great majority of cases 
tubercular ileo-colitis is secondary to tuberculosis elsewhere, and in such 
cases is followed by tuberculosis of the mesenteric glands. The most 
common source of infection, however, in all parts of the gastro-enteric 
tract, is from the lung, by means of the sputum which has been swal- 
lowed. 

Pathology. — The tubercular lesions are most common at the lower 
end of the ileum, next in the rectum, and then in the colon. In tubercu- 
losis of the intestine the corresponding lymph-nodes are always affected. 
The tubercular lesions almost invariably occur in the form of ulcerations. 
These ulcers begin both in the solitary follicles and in Peyer's patches. 
The ulcers in the solitary follicles are small. In Peyer's patches they 
may be large, involving the entire extent of the patch. They also show 



400 PEDIATRICS. 

a tendency to grow in the direction of the lymphatics, so that an ulcer 
may extend around the entire circumference of the intestine. The tuber- 
cular ulcer has the following characteristics : in contradistinction to the 
typhoidal ulcer, the long diameter of which coincides with the long axis 
of the intestine, the tubercular ulcer is transverse to the long axis, rarely 
ovoid, and often irregular in outline. The edges overhang and the base 
is infiltrated, and in many instances small tubercles may be visible to the 
unaided eye on the peritoneal surface at the base of the ulcer. 

Fig. 101 represents a specimen of tubercular disease of the intestine 
which occurred in the practice of Dr. Northrup. 

A girl eight and a half years old was attacked two months before her death with 
chills, fever, and prostration. The temperature at first varied from 38.8° to 39.4° C, 
(102° to 103° F.), but as the disease progressed the temperature gradually fell. There 
was rapid emaciation, the abdomen was sunken at first, but later became tense. 
There were pain, tenderness, and resistance in the right inguinal region. The sub- 
maxillary, cervical, and inguinal lymph-nodes were enlarged. The urine contained 
albumin and hyaline casts. There was diarrhoea. The autopsy showed the lungs to 
be normal. The bronchial and retro-peritoneal lymph-glands were enlarged and 
cheesy. The colon showed two large sloughing ulcers, one in the region of the caecum 
and the other in the ascending portion. They were transverse to the axis of the colon, 
and their edges were overhanging. The entire membrane was thickened, and there 
was some follicular ulceration. 

Fig. 102, I. and II., represent portions of intestine taken from a girl two years and 
eight months old. She had had diarrhoea occasionally for a year and also convulsions. 
She died soon after entering the hospital. The autopsy showed extensive ulcerations in 
the small intestine (I.), and a large ulcer in the caecum (II.). There were tubercular 
ulcers in the middle third of the colon. The peritoneal surface showed miliary tuber- 
cles. The mesenteric and bronchial lymph-glands were markedly enlarged and cheesy. 

Symptoms. — The symptoms of tubercular ileo-colitis are varied and in- 
definite. The most common symptom is a persistent diarrhoea. The 
diarrhoea, however, does not correspond to the extent of the lesions, as 
large ulcers may exist and constipation be present, especially if they are 
in the ileum. 

Diagnosis. — In cases of primary tuberculosis of the intestine, the only 
certain means of determining the tubercular character of the disease is to 
find the tubercle bacillus in the discharges. When the disease is second- 
ary to tuberculosis elsewhere, the tubercular involvement of the intestine 
may be suspected, when at any time during the course of the disease the 
infant is attacked with diarrhoea of an obstinate nature. In these cases the 
disease can only be established by finding the tubercle bacillus in the dis- 
charges. It is exceedingly difficult to do this when the stools are watery. 
It has been suggested that in order to simplify the search for the specific 
organism, sufficient opium should be given to produce a constipated move- 
ment, so that the smears may be taken from the mucus which is scraped 
from the tubercular ulcers and clings to the hard faecal masses as they 
pass downward along the course of the intestine. 



Fig. 101 




Tubercular ulcers of colon. Female, 8% years 
old. Museum of the College of Physicians and Sur- 
geons, New York. 



Tubercular ulcers of small intestine. Female 
2% years old. Museum of the College of Physi- 
cians and Surgeons, New York. 




Large tubercular ulcer of caecum. 



SPECIFIC INFECTIOUS DISEASES. 401 

The differential diagnosis is to be made from chronic non-tubercular 
ileo-colitis. In the latter condition the history usually shows that the dis- 
ease has begun with an acute attack, while in tuberculosis the onset has 
been insidious. Markedly enlarged mesenteric nodes and the evidence 
of tuberculosis elsewhere are important as indicating a tubercular cause 
for the intestinal symptoms. 

Prognosis. — The prognosis is very unfavorable, and death may occur 
either from the severity of the intestinal symptoms, or, more rarely, by 
perforation or hemorrhage. The prognosis, however, largely depends on 
that of the tubercular disease to which the intestinal tuberculosis is sec- 
ondary. 

Treatment. — The treatment is the same as that described for non- 
tubercular ileo-colitis on page 823. 

TUBERCULOSIS OF THE PERITONEUM. 

Tuberculosis of the peritoneum may occur in both infants and chil- 
dren, but a marked inflammatory condition, either with or without ascites, 
is more common in children than in infants. In infants it is more com- 
mon to have a miliary tuberculosis of the peritoneum in the course of a 
general tuberculosis which does not, as a rule, show abdominal symptoms. 
In children the peritoneal inflammation may be so markedly localized as 
to constitute a disease of itself, tubercular 'peritonitis. 

Etiology. — The original source of the tubercular process is often ob- 
scure. It may be a primary infection of the peritoneum, but most com- 
monly is secondary to tuberculosis of the mesenteric nodes. It may also 
be secondary to tuberculosis of the intestine, lungs, lymph-nodes in vari- 
ous parts of the body, and other organs. It may arise in the course of 
the various infectious diseases, especially the exanthemata. Tubercular 
peritonitis may be acute or chronic, but the most common form met with 
in children, and the one which usually represents the disease clinically is 
the chronic. 

Pathology. — The process consists in the formation of miliary tuber- 
cles on the peritoneal surface, which give rise to opaque cheesy thicken- 
ings, often nodular, with firm adhesions of the adjacent surfaces. An 
exudation into the peritoneal cavity is usually present, the quantity gen- 
erally being considerable and sero-purulent in character. The ascites 
may, however, be serous, or merely purulent. 

The disease may occur in three forms. (1) A miliary tuberculosis 
with ascites acute or subacute in its course. (2) A fibrous form in which 
ascites may be, but is not usually, present. This form is essentially 
chronic. There is a formation of a fibrous tissue with matting of the 
intestine, of the omentum and mesentery, and not much tendency to 
caseation or breaking down. (3) An ulcerative form, which is a later 
stage of the two forms just described, and in which occur large tubercular 
deposits with caseation and softening. The lungs in this form are affected. 

26 



402 PEDIATRICS. 

It is not so chronic as the fibrous form (2), but it is characterized by more 
fever and more severe symptoms. 

Symptoms. — The symptoms of tubercular peritonitis vary according to 
the extent and character of the lesions. When they consist of a miliary 
tuberculosis of the peritoneum, with only a slight inflammatory condition, 
they are usually secondary to a general tuberculosis, and the abdominal 
symptoms are insignificant. When this form occurs in young infants the 
later manifestations of abdominal disease are seldom seen, as the infant 
usually succumbs to the infection before the symptoms have had time to 
develop. When the disease is acute, the symptoms, as a rule, develop 
in connection with, or most often following, the symptoms of tuberculosis 
elsewhere, especially in the lung, and do not differ materially from those 
of acute non-tubercular peritonitis. When the disease is of the subacute 
and chronic form the symptoms vary according to the presence or ab- 
sence of ascites as a prominent condition. Here, again, the symptoms 
correspond to the character of the lesions. In either case a tubercular 
process is going on, but in one it results in a large effusion of fluid, while 
in the other the more advanced tubercular lesions develop with no fluid 
at all, or with only a small amount. 

The initial symptoms of tubercular peritonitis, with gradual develop- 
ment of ascites, are usually ill defined. There is a gradual loss of appe- 
tite and flesh, with occasional abdominal pain, which, as a rule, is not 
severe in character. There is seldom any tenderness of the abdomen. 
Vomiting is not a marked symptom. Attacks of diarrhoea are common 
and are apt to be paroxysmal. There may be constipation. The tem- 
perature is at times raised, especially in the latter part of the day, but, as 
a rule, is moderate,— 37.2° to 38.8° C. (99° to 102° F.) — and maybe so 
nearly normal as to simulate ascites due to obstruction. After these gen- 
eral symptoms have lasted for a number of weeks, the abdomen is 
noticed to be distended. A physical examination may show that there is 
nothing abnormal in the thorax, and that the morbid condition is confined 
entirely to the abdomen.. At first the abdomen is resonant on percus- 
sion, but later fluctuation is detected. While for a time there is reso- 
nance in the region of the umbilicus when the child is lying on its back, 
and a change in the area of resonance with a change of position, this area 
of resonance gradually grows less. The fluid, however, may be encapsu- 
lated by adhesions and thus the area of dulness and resonance be less 
distinctly followed. As the disease progresses and the fluid increases, the 
whole abdomen becomes much distended and tense, the abdominal veins 
prominent, and the dulness and fluctuation diminished. In this higher 
grade of ascites the umbilicus is at times found to be pushed out by the 
fluid. 

Clinically separated from the class of cases with ascites as the promi- 
nent symptom, are the still more chronic cases in which ascites is not 
prominent, but in which there are tubercular processes which, because of 



SPECIFIC INFECTIOUS DISEASES. 403 

certain mechanical conditions, result in a set of symptoms induced by 
pressure, such as oedema, digestive disturbance, and renal congestion. The 
general symptoms are about the same as in the ascitic form just de- 
scribed, the difference being in the conditions found on examining the 
abdomen. Possibly the onset is still more insidious than in the other 
form, and the temperature more likely to be normal. The abdomen 
may be distended and tympanitic, or, again, varying areas of dulness 
may be detected, depending usually on tuberculous masses or tubercu- 
lous thickening of the greater omentum. There may at times be a cer- 
tain amount of fluid which can be detected by fluctuation and change of 
position. Although there may be abdominal pain and tenderness, yet 
usually these symptoms are absent, and sometimes markedly so, even 
when the process has gone on to a purulent ascites. 

The cases in which the more advanced tubercular lesions, such as 
ulceration and breaking down of the tubercular growths, have taken 
place are usually secondary to advanced lesions elsewhere, as in the lung, 
and do not properly constitute a localized tubercular disease. In these 
cases, however, the temperature is raised, a hectic condition is commonly 
present, the wasting is extreme, and all the symptoms irregular, so that 
when these symptoms become marked in the other forms of tubercular 
peritonitis just described, the presence of a general tuberculosis should at 
once be thought of. 

Diagnosis. — In a case in which the symptoms which have just been 
mentioned are present the diagnosis is not difficult. Occasionally, how- 
ever, there are no definite signs by which a diagnosis can be made, the 
only tangible sign being a seeming abdominal tumor, the resemblance of 
which to other abdominal tumors is so close that the diagnosis can only 
be made by laparotomy. We should remember, however, that most cases 
of doubtful abdominal tumors in children are tuberculous. In a case in 
which there is considerable ascites, it should be recognized that while 
the most frequent form of ascites in adults is obstruction of the portal 
circulation, as in cirrhosis, in young children, on the contrary, portal ob- 
struction is rare, while ascites from tubercular peritonitis is exceedingly 
common, and is the disease which should at first be thought of. The 
greatest difficulty arises in differentiating simple non-tubercular peritonitis 
Avith ascites from the tubercular form. It is often impossible to do this 
without an exploratory paracentesis. If, however, there is evidence of 
tuberculosis elsewhere, or if the fluid is encapsulated, or if there is con- 
siderable fever, the process is most likely to be tubercular. In the cases 
of tubercular peritonitis where there are tubercular lymph-nodes without 
ascites, the diagnosis can only be made if irregular masses can be detected 
in the abdomen, accompanied by fever, wasting, and possibly some ab- 
dominal tenderness not accounted for by disease elsewhere. If tubercular 
disease is detected in the lungs, the diagnosis is still more assured. In 
many cases, however, the diagnosis can only be made by abdominal para- 



404 



PEDIATRICS. 



centesis. The diagnosis of the advanced cases, in which ulceration has 
taken place, is usually to be made as part of a tubercular condition of 
other organs, especially the lung. 

Prognosis. — When tubercular lesions of other organs are present the 
prognosis is bad. In those cases in which the tuberculosis is apparently 
confined to the abdomen, the prognosis has been much improved since 
the employment of laparotomy for treatment. Any of these cases may, 
however, eventually die from a later infection, as of the brain or lung. 
When untreated the prognosis of tubercular peritonitis is very variable. 
In some cases the disease after a number of months retrogrades and the 
patient recovers. In most instances the child becomes more and more 
wasted, the fever becomes more pronounced, the diarrhoea continues, the 
emaciation becomes extreme, and the child dies usually of exhaustion. 
The surgical treatment of the disease has made the prognosis much more 
favorable. 

Treatment. — -The general treatment of tubercular peritonitis does not 
differ from that of the non-tubercular form (see page 843). The essential 
treatment, however, in the cases which are supposed to be localized is 
surgical, especially when there is ascites of any amount. In some cases 
opening the abdomen and evacuating the fluid will not only give relief, 
but will produce a permanent cure. In my experience at the Boston 
Children's Hospital thi? procedure has been in a large number of cases 
followed by a complete arrest of the disease. Cases of marked tuber- 
cular peritonitis in which laparotomy had been performed, have been re- 
ported as perfectly well some years after the operation. 

Fig. 103 represents a colored boy, nine years old, with tubercular peritonitis. His 
father died of phthisis. The boy had never been strong, but had suffered no acute 

Fig. 103. 




Tubercular peritonitis. Male, 9 years old. 



illness. Three weeks previous to my seeing him, he began to have diarrhoea, and soon 
after, enlargement of the abdomen. There was no pain, vomiting, nor cough. He 
had lost greatly in weight and was much emaciated. His temperature was 38.3° C. 
(101° F.). The abdomen was much distended and gave a distinct wave of fluctua- 
tion. Physical examination showed nothing else abnormal. 

Laparotomy was performed and the fluid evacuated. Tubercle bacilli were found 
in the peritoneal tissue. When seen six months later the wound had healed perfectly, 
and he was strong and well. 

Another case was that of a boy, two years old, and is especially interesting in 
regard to the diagnosis. 

He had not had general symptoms of serious import, but had lost slightly in weight, 
appetite, and strength. From time to time for six months he complained of abdominal 



SPECIFIC INFECTIOUS DISEASES. 405 

pain and tenderness. An examination of the abdomen showed a hardened, slightly 
irregular mass extending directly across the abdomen from one side to the other, 5 cm. 
(2 inches) above and the same distance below the umbilicus. It was not especially 
tender on pressure. Nothing else abnormal was detected about the child. The line 
of percussion did not change when he was lying on his back. There was no evidence 
of ascites. Laparotomy was performed and a mass of cheesy nodules matting together 
the intestine was found. An examination of a portion of this mass showed the pres- 
ence of the tubercle bacillus. No fluid was present. The child recovered. 

The next case was that of a boy, four years old, brought to the hospital with the 
extreme distention of the abdomen which is represented in Fig. 104. A physical ex- 
amination showed nothing abnormal except in the abdomen, which was dull on per- 

Fig. 104. 




Tubercular peritonitis. Male, 4 years old. 

cussion and showed fluctuation in every part. The child had gradually lost in weight, 
appetite, and strength. Laparotomy was performed and a large amount of ascitic fluid 
evacuated. Tubercle bacilli were present in the diseased peritoneum. The wound 
healed, but in the course of a few weeks the fluid re-accumulated, and laparotomy was 
again performed. Some weeks after the second operation no fluid could be detected. 
There was no recurrence of the ascites, and the child recovered completely. 

The next case is that of a boy, eleven years old. He had been perfectly well until 
four months before coming to the hospital, when he began to lose in weight and appe- 
tite and to show an increase in the size of his abdomen. Although he was not espe- 
cially emaciated, he had lost in flesh and was pale. The circumference of the abdomen 
was 76.4 cm. (30 inches). On physical examination, nothing abnormal was detected 
in any of the other organs. For some months before the boy showed peritoneal symp- 
toms, he had been drinking the milk of a tubercular cow. Laparotomy was per- 
formed and a large amount of serous fluid of a dark yellow color was removed. The 
peritoneum was found to be thickly studded with minute tubercles, and tubercle bacilli 
were demonstrated. The peritoneal cavity was irrigated and drained. He recovered 
completely from the operation, and when examined four years later, was found to be 
well and strong, and to show no signs of tubercular disease. 

TUBERCULOSIS OF THE CEREBRO-SPINAL SYSTEM. — 
Tuberculosis of the cerebro-spinal system usually takes the form of an 
infection of the meninges (tubercular meningitis), and is found most com- 
monly in the meninges at the base of the brain. As a rule, the disease is 
never so extensive in the spinal as in the cerebral meninges. Some- 
times, though very rarely, a growth of miliary tubercles in the meninges 
extends into the tissues of the brain. The tubercle bacilli themselves are 
usually confined to the brain, but they may extend to the lungs and pro- 
duce definite foci of embolic pneumonia. 



406 PEDIATRICS. 

TUBERCULOSIS OF THE BRAIN. 

Pathology. — Tuberculosis of the brain may occur in the form of 
scattered miliary tubercles, or these tubercles may occur as nodular 
masses of various sizes formed by aggregations of miliary tubercles. These 
nodular masses may be single, but are more commonly multiple, and are 
found in both the cerebrum and cerebellum, but most frequently in the 
latter. They are occasionally found in the crus. 

Symptoms. — Tubercular lesions of the brain are always terminal. The 
scattered miliary tubercles are usually a part of a general miliary tubercu- 
losis, and usually do not produce any special cerebral symptoms. When, 
however, masses of tubercles large enough to be considered tumors are 
present, they present the symptoms of cerebral tumor as described on 
page 978. In some cases tubercular tumors of considerable size have 
been found at the autopsy, when during life no symptoms have been 
noted. Such a case is described on page 980. 

Prognosis. — Although these tubercular lesions of the brain may remain 
latent during long periods, as a rule they result fatally, so that the prog- 
nosis is very bad. 

Treatment. — The use of drugs in these cases is not of very much 
benefit. Surgical interference has proved of value when we are assured 
that a tubercular condition is present. 

TUBERCULAR MENINGITIS. 

Etiology. — Tubercular meningitis is a tubercular infection resulting in 
an inflammation of the pia mater. It is not a primary disease of the 
meninges, but is always a terminal lesion produced by the tubercle bacillus, 
which, originating elsewhere, is carried to the brain by the lymphatics or 
the blood-vessels. In infants the tubercular meningitis is usually second- 
ary to a general tuberculosis or to tubercular lesions in the lungs. In 
older children it is apt to be secondary to tuberculosis of the lymph- 
nodes, bones, or joints. The tubercular form of otitis is not uncommon, 
and may be the starting-point of a meningeal infection. Tubercular 
meningitis is the most common form of meningeal disease in children. It 
occurs most commonly in early life, runs a subacute course, and is invari- 
ably fatal. It occurs more commonly between the ages of two and seven, 
than at any other period of life. It is rare in the first year of life, espe- 
cially in the early months ; the number of cases increases rapidly in the 
second year and decreases as rapidly after the eighth year. It is com- 
paratively so rare in adult life that out of a large number of adult pa- 
tients that I met in my service at the City Hospital only a few cases of 
tubercular meningitis came under my care during a service of ten years. 
In a large number of cases there is a tubercular history of one or both 
parents. 

Pathology. — A knowledge of the general pathology of tubercular 
meningitis is of great practical importance in acquiring a clear picture of 



SPECIFIC INFECTIOUS DISEASES. 407 

the disease. Although the nidus of the tubercle bacillus which produces 
the pathological lesions of tubercular meningitis is in some other part of 
the body, and the lesions of the brain and its meninges are always second- 
ary, yet, as the clinical characteristics of the disease are those of a pri- 
mary cerebral nature, only the morbid lesions which occur in the brain 
will be described. 

The macroscopic pathological condition which is seen in the brain as 
a result of the action of the tubercle bacillus is a growth of miliary tuber- 
cle in the meninges. This growth is especially marked in the meshes of. 
the pia mater along the course of the blood-vessels at the base of the 
brain. These small granulations are conspicuously numerous in the choroid 
plexus, and cause great irritation in the neighboring parts. The irritation 
is followed by an exudation of greater or less extent into the ventricles. 
Accompanying this there is also a fibrino-purulent exudation between the 
pia mater and the cerebral convolutions at the base of the brain, notably 
in the fissures of Sylvius, but at times covering the whole convexity. 
This inflammatory exudation is usually confined to the meninges, but it 
may extend into the tissue of both brain and cord and over the upper 
surface of the cerebellum. A marked characteristic of the disease, and 
one which tends to distinguish it from other forms of meningitis, is the 
extension of the exudation from the meninges around the sheaths of the 
cranial nerves. The nerves apt to be affected are the auditory, optic, and 
the fifth nerve. The amount of exudation is not proportionate to the 
number of tubercles. The ventricles are sometimes so distended as to 
burst the septum. Pressure is thus brought upon the central portions of 
the brain, involving especially the optic thalamus, the corpus striatum, 
and the corpus callosum. While the symptoms vary in different indi- 
viduals and at different ages, the pathological lesions, on the other hand, 
with the exception of their location, are comparatively stable. What is 
of especial interest to us clinically, however, is that, although in a typical 
case of tubercular meningitis in middle childhood the symptoms, as a 
rule, correspond to the pathological lesions, yet in some cases we find an 
entire lack of such symptoms as would naturally result from the wide- 
spread and prominent lesions. The spinal meninges are occasionally 
involved in tubercular spondylitis (Pott's disease). 

Symptoms. — Tubercular meningitis presents many irregularities in its 
manifestations, and its typical symptoms vary according to the age of the 
patient. By careful study of the pathology of tubercular meningitis we 
can almost deduce the sequence of symptoms which we should expect to 
meet with in the middle period of childhood, a period when the disease is 
seen in its most typical form. In fact, in the great majority of cases oc- 
curring between the ages of two and eight years this sequence is very 
striking. As we are dealing with a symptom of general tuberculosis, we 
should expect to find in the early stages of the disease that the nutrition 
is affected, that there are a lessened appetite, loss in weight, anaemia, and, 



408 



PEDIATRICS. 



ir fact, symptoms which warn us that something is affecting the child's 
general health. This condition may last for many weeks, or even months, 
varying as to the time when the tubercle bacillus has left its original 
nidus and migrated to the cerebral meninges. Only after this has occurred 
do we begin to get symptoms of cerebral irritation. The child then be- 
comes peevish and capricious, and is in some cases easily frightened. As 
the tubercular growth increases and causes further congestion of the 
blood-vessels, the sleep is disturbed ; the child complains of dizziness and 
.slight evanescent pains in the head ; it staggers slightly in its walk (static 
ataxia) ; sometimes it cries out sharply, especially at night (hydrocephalic 
cry). Vomiting, apparently not connected with the food, and usually 
without nausea, is a common symptom. It may occur only once or 
several times, or it may last for a number of days. These are symptoms 
of irritation of the nervous centres, and may last for a week or two, ac- 
cording to the development of the pathological lesions. Progressive 
emaciation becomes prominent, and the increasing apathy is very notice- 
able. 

The temperature is usually moderately raised, 37.2°-37.7°-38.3° C. 
(99°-100°-101° F.), but on some days it rises a degree or so higher, and 
just before death a considerable elevation may occur. Chart 6 shows the 

CHART 6. 





Days of Disease. 




F. 


i 


2 


s 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


16 


17 


18 


19 


c. 


107° 
106° 
105° 
104° 
103° 
102 • 
101° 
100° 
99° 

NORM'L 
TEMP. 

98° 

97° 

96° 
95° 


MM 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


M E 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME! 


ME 


ME 


41-6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 
35.0 • 




















































































































su 






































S 






































o 


















/ 














A 






^ 




/ 


,/ 








J 


/ 


V 


U" 


V 
















7 


,/ 


V 


V 


v' 


— ■ — 


[/' 


V 


V 






















A 


V 























_.... 









i — 















































































































































Tubercular meningitis. Male, 4 years old. 



temperature of a child four years old. It represents very well what will 
usually be met with in uncomplicated cases of tubercular meningitis. It 
is impossible to determine the exact day of the beginning of the disease in 
such an affection as tubercular meningitis, so that the first day marked on 
the chart is merely approximate and serves as a starting-point to show 



SPECIFIC INFECTIOUS DISEASES. 409 

the character of the temperature. The pulse at first is somewhat accel- 
erated, but soon becomes slower than normal, and is apt to intermit. In 
determining whether the pulse is siow, the age of the child must be taken 
into consideration. (See page 71.) The respirations may in the early 
part of the disease be quickened, and at times are of a sighing character. 
Obstinate constipation is a common symptom. The urine is scanty. 
Hyperesthesia of the skin, Avith occasional waves of congestion, especially 
of the cheeks, is sometimes met with. The pain in the head increases, 
and the child is apt to hold its hand to its head, Drowsiness, at first 
slight, soon becomes very marked, and gradually changes to stupor, diffi- 
culty in arousing the child becoming greater and greater. The child is 
apathetic and lies in bed, refusing to eat. There is photophobia, and the 
pupils may, early in the disease, be contracted. Tubercles in the fundus 
of the eye are rarely seen during life. The eyes have a fixed, expression- 
less look. Abdominal pains are quite frequent, and depression of the 
abdomen (boat-shaped) is noticed in a certain number of cases. Drawing 
the fmger over the skin usually produces a bright red line, which be- 
comes in a few minutes quite intense, and lasts perhaps ten or fifteen 
minutes, which is much longer than would be the case in a healthy child. 
This phenomenon is called the tache cerebrale, and is quite frequently met 
with in tubercular meningitis, although it may be absent. This sign is, 
however, in no sense typical, and is seen in a number of other diseases. 
Kernig's sign may or may not be present. The child at this stage of the 
disease is apt to roll its head on the pillow almost continuously. If 
diarrhoea appears, we should suspect tuberculosis of the intestine. 

When the pathological irritation has gone on to exudation, we begin to 
get symptoms of pressure. Sopor comes on-rapidly, and the child can no 
longer be aroused. Strabismus, nystagmus, and ptosis may appear. The 
pupils are dilated and irregular, respond slowly to light and later not at 
all. The cornea becomes clouded. The Meibomian secretion is some- 
times markedly increased. Muscular twitching may occur. Convulsions, 
generally partial, and of a rather mild type, set in. Rigidity of the neck 
and, at times, opisthotonos develop. Movement of the head and trunk and 
pressure over the spinous processes may cause pain. At times paralysis 
of the arm, or of the arm and leg (hemiplegia), and interference with 
sight (optic neuritis), may be noticed. The cutaneous reflexes are dimin- 
ished and the deep reflexes of the arms and legs are, as a rule, increased. 
The paralysis which in some cases occurs early in the disease is not 
necessarily permanent. At this stage the pulse becomes markedly slow 
and irregular, 50-60-70, and it is very common to find an intermis- 
sion in the pulse, although this must not be considered as diagnostic 
of tubercular meningitis. The respirations are not perceptibly diminished 
at first, but soon become slow, 10 to 15 in a minute. A peculiar 
form of respiration, called Cheyne-Stokes, is usually seen at this stage of 
the disease. The type of respiration is characterized by complete or 



410 PEDIATRICS. 

almost complete cessation of the respiratory movements for a number of 
seconds. This is followed by a faint return of the respiratory move- 
ments, which gradually increase in depth, rising for five or six inspirations 
and then fading away again so as to be imperceptible. Chart 7 repre- 

CHAKT 7. 




Pause. 
Cheyne-Stokes respiration. Tubercular meningitis. Child, 4 years old. 

sents this type of respirations. Leucocytosis may or may not be present. 
Iodophilia is absent. 

A heightened temperature in tubercular meningitis indicates a compli- 
cation of some kind, such as pulmonary tuberculosis, pneumonia, or tuber- 
culosis of the intestine. At the end of the disease, however, the temper- 
ature rises rapidly, as do the pulse and respirations. Hearing, taste, and 
smell seem to be unimpaired for some time. The position which children 
with tubercular meningitis often take is somewhat characteristic. In all 
forms of meningitis they are apt to bury their heads in the bedclothes, 
and there is often spasmodic retraction of the head. They are inclined 
to lie with their knees drawn up, and there may be spasmodic opisthot- 
onos. A striking feature which not infrequently occurs in the course of 
these general symptoms is a partial return to consciousness after the child 
has been lying in a stupor for several days. This phenomenon often in- 
duces the parents, and sometimes even the physician, to entertain hopes 
of improvement. It is, however, always delusive, for it has no favorable 
significance, and is soon followed by a more profound state of uncon- 
sciousness. These symptoms which been have mentioned do not, of 
course, always appear together, but may be present in different groups, 
varying with the individual. All the symptoms may disappear temporarily. 

The duration of the disease varies. It is usually from three to six 
weeks, but may last only one week, and again eight or even twelve weeks. 
The cases of shorter duration usually present more active and severe 
symptoms, and ones more difficult to differentiate from simple acute 
meningitis. Death may be preceded by continued convulsions for several 
hours, but usually the pulse becomes weaker, the temperature rises, the 
child can no longer be made to swallow, and, according to Sachs, dies 
from paralysis of the cardiac and respiratory centres. 

Infantile Tubercular Meningitis. — Symptoms. — According to some 
extended observations made at the hospital in Stockholm, infantile tuber- 
cular meningitis is characterized in the first year by an absence of prodro- 
mata, the sudden development of acute symptoms, a short course, and a 
fatal issue. The temperature is high,— 38.8 °-39.4°-40° C. (102°-103°- 



SPECIFIC INFECTIOUS DISEASES. 411 

104° F.) The respirations are quickened and comparatively regular, — 
30-40-50. The pulse is high, — 130-140-150. Clonic spasms and 
strabismus often occur. Paralysis is quite frequent, and diarrhoea is 
present rather than constipation. Bulging of the fontanelles is usual. 
Sinking of the abdomen is rare. Vomiting may occur, but is not espe- 
cially common. Sharp cries are occasionally met with. The differential 
diagnosis from non-tubercular meningitis is difficult. Sopor and coma at 
the end are frequent in both diseases. The duration is seldom more than 
a week. It may be only two days, yet in rare cases the infant, like the 
child, may live for a month. 

During the second year the symptoms of tubercular meningitis become 
of an irregular type, sometimes assuming the character of those which are 
seen in the first year, but soon corresponding more nearly to those which 
are met with in the middle period of childhood. 

Diagnosis. — The diagnosis of tubercular meningitis in the middle 
period of childhood, and with the sequence of symptoms just described, 
is not difficult, but in the early days, or even in the first week of the 
disease, must necessarily be very obscure. When the process occurs in 
young infants the difficulty is still greater. It is by watching the course 
of the disease and the general grouping of symptoms, rather than by the 
consideration of any one symptom, or even one group of symptoms, that 
we are justified in making a definite diagnosis. The diagnosis, then, must, 
as a rule, be held in abeyance for many days. Reflex vomiting with a 
moderate temperature, irregularity and intermission of the pulse, apathy, 
and many other symptoms of tubercular meningitis I have seen in cases 
in which there were no serious cerebral lesions. The active development 
and sensitive condition of the nervous system in children are so exagger- 
ated in comparison with those of adults, that whatever condition may be 
present, it is liable to produce so profound an impression on the child's 
nervous centres that actual disease of these centres is readily simulated. 
Thus, for days symptoms apparently cerebral may mask by their undue 
prominence the presence of the real disease. 

As a rule, in most cases the distinctive picture of a beginning tuber- 
cular meningitis after the first year of life closely simulates that of a simple 
digestive attack. Reflex vomiting, continued for some time without ade- 
quate explanation, and progressive loss in weight and strength, with 
change in temperament, should awaken suspicion of the more serious 
disease. Marked constipation, apathy, and drowsiness, slowly increasing 
stupor, and slow, irregular pulse and respiration, with a moderate tem- 
perature, will strengthen the diagnosis. Confirmatory evidence of the 
presence of tubercular meningitis can be obtained in many cases by means 
of lumbar puncture. The differential diagnosis from other diseases and 
the presence of some form of meningitis can readily be made by the 
cerebro-spinal fluid, which contains some form of pathogenic organism 
and is usually cloudy. The cerebro-spinal fluid in tubercular meningitis 



412 PEDIATRICS. 

contains cells which are essentially lymphoid in character, the polymor- 
phonuclear leucocytes being much less numerous. In addition to this, 
the fluid is less turbid than in the other forms of meningitis. Cover-glass 
preparations may show the tubercle bacillus, and inoculation of the fluid 
will often produce tuberculosis in guinea-pigs. 

In the other forms of meningitis, including the epidemic cerebro-spinal 
form, the cells are mostly of the polymorphonuclear variety, while the 
lymphoid cells are less numerous. The fluid is also more cloudy than in 
the tubercular form. In addition to this, some special organism may be 
found, such as the pneumococcus in cases of pneumonia, and the diplo- 
coccus intracellularis in the epidemic form. 

Differential Diagnosis. — The differential diagnosis must be made be- 
tween meningitis in general and other diseases, such as (1) diseases of the 
stomach, (2) anterior poliomyelitis, (3) pneumonia, (4) malaria, (5) typhoid 
fever, (6) syphilis, (7) nephritis, (8) epidemic cerebro-spinal meningitis, 
and (9) acute meningitis. 

(1) From Diseases of the Stomach. — Unless the child is very young, 
symptoms due to acute gastric disturbance are, as a rule, not difficult to 
recognize after the first few days. We may at times, however, be sus- 
picious of cerebral disease when in an infant there is continual vomiting 
and an elevated temperature, in whom there is no discoverable source of 
reflex irritation to account for the symptoms. This is especially the case 
if there is some irregularity of respiration and the pulse is slow. These 
may prove to be cases of tubercular meningitis in the first year of life. 
Again, however, they may be simply cases of reflex vomiting. As an illus- 
tration of this class of reflex gastric disturbance the following case may be 
cited : 

A male infant, eight months old, was attacked with vomiting which lasted with 
short intervals for two days. There was apathy, and the pulse was slow and intermit- 
tent. The temperature was 37.2° C. (99° F.). There were irregular respiration and 
rapid emaciation. The patient made a perfect recovery in four or five days, and the 
case proved to be one of cyclic vomiting. The slow, intermittent pulse, and the 
moderate temperature, which would have been so alarming in an older child, led me 
in this case, as in others in the first year of life, to eliminate tubercular meningitis. 
In my experience this interpretation of symptoms has proved to be correct. 

(2) From Anterior Poliomyelitis. — The following case of anterior polio- 
myelitis resembled tubercular meningitis : 

A boy, eighteen months old, showed for over a week symptoms closely simulating 
those of tubercular meningitis. Obstinate constipation and apathy were present, fol- 
lowed by unconsciousness ; there were also a marked tache cerebrale, distended fonta- 
nels, irregular pulse, contracted pupils, eyes turned upward, and convulsive attacks. 
Finally, paralysis of the arms appeared, the general symptoms passed off, and the diag- 
nosis of anterior poliomyelitis was readily made. 

(3) From Pneumonia. — A certain number of both primary and 
secondary cases of meningitis have been proved to have been caused 



SPECIFIC INFECTIOUS DISEASES. 413 

by the pneumococcus lanceolatus, but the number as yet has been too few 
to formulate a symptomatology separate from that of the other forms of 
meningitis. The cases of pneumonia reported on page 682 warn us 
that we should hold our diagnosis in abeyance sometimes even for a 
week, and that the nervous symptoms arising in the course of a pneu- 
monia may closely simulate those arising from meningitis. 

(4) From Malaria. — Although we must admit that malaria closely sim- 
ulates almost any disease, it is not usual to mistake the malaria of older 
children for tubercular meningitis. An examination of the blood for the 
presence of the plasmodium will generally make the diagnosis clear. In 
the first two years of life, however, malaria may affect so insidiously 
the general nutrition before its characteristic symptoms appear that some 
doubt as to the differential diagnosis may arise, as illustrated in the fol- 
lowing case : 

A male infant, twenty months old, with a history of tuberculosis on the mother's 
side, began to show symptoms of anaemia and malnutrition with no perceptible cause, 
such as improper food or bad general hygiene, to account for it. After two or three 
weeks it had attacks of unconsciousness lasting for hours ; at other times drowsiness, 
with irregular pulse and respirations, was noticed. The temperature was 39.5° to 40° 
C. (103° to 104° F.). There were slight convulsions, and the fontanelles were dis- 
tended. At first there was no periodicity of the symptoms, but a week later the 
attacks were evidently more pronounced every other day, while on the intervening days 
the infant was brighter. It lived in a malarial district. On the administration of 
quinine and on removing the infant to a non-malarial region, these symptoms entirely 
disappeared. The detection of the plasmodium would, of course, have determined 
the diagnosis in this case, but it could not be obtained. 

Another case, which I saw in consultation, is also very instructive in 
warning us to be careful in making a diagnosis of tubercular meningitis 
in cases in which there is a possibility of malaria being the cause of the 
symptoms. 

A male infant, fourteen months old, had always been well until fourteen days pre- 
vious to the time when I first saw it. It then began to be fretful and to have diarrhoea. 
This condition continued for about a week, when it fell into a stupor, became very 
anaemic, and it was necessary to feed it by means of a dropper. At times it would cry 
out sharply. The temperature varied from 37.2° to 38.7° C. (99° to 102° F.). The 
respirations were usually regular, but at times were of the Cheyne-Stokes type. The 
pulse was about 120, sometimes regular, but at times intermitting. The pupils were 
sometimes contracted, but showed no irregularity. No other abnormal conditions were 
detected, but the abdomen was depressed. The tache cerebrate was very distinct. 

On close inquiry I found that there was a slight periodicity in the symptoms, shown 
by a rise of temperature on each afternoon and followed by the stupor becoming some- 
what less. Although the infant had been unconscious for a week, and was becoming 
weaker and taking less nourishment every day, yet, on the supposition that it might 
possibly be an obscure case of malaria, I decided that quinine should be administered 
in suppositories. On the next day a slight improvement was noticed during the after- 
noon. The infant appeared less comatose, but its temperature and pulse remained as 
on the previous days. On the following day, which was the second from the time that 



414 PEDIATRICS. 

it had begun to receive the quinine, it rapidly became conscious and began to drink 
milk. On the following day it was reported to have had a restless night and two slight 
convulsions. Its temperature in the morning was 38.2° C. (100.9° F.), and the pulse 
was 115 and not intermittent. On the next day there was marked improvement in 
every way, and this continued without interruption. 

(5) From Typhoid Fever. — In my experience in cases in which positive 
results are not obtained from the Widal reaction and from lumbar punc- 
ture, typhoid fever in young children is the disease which, next to the 
non-tubercular forms of meningitis, is most likely to simulate and be mis- 
taken for tubercular meningitis. The differential diagnosis is given on 
page 453. We may also have considerable difficulty in differentiating tu- 
bercular meningitis from the non-tubercular meningitis which may occur 
in the course of typhoid fever ; this form of meningitis, though exceedingly 
rare, may occur, as has been proved by finding the typhoid bacillus in the 
cerebro-spinal fluid by lumbar puncture. The extreme cerebral con- 
gestion which at times arises as a symptom of typhoid fever may also add 
fresh difficulties to the differential diagnosis. 

(6) From Syphilis. — The history and general symptoms of syphilis are 
to be sought for where a syphilitic meningitis is suspected. The temper- 
ature is not especially high, and the symptoms are seldom acute. The 
pathology is said to be usually that of a chronic basic meningitis. 

(7) From Nephritis. — In addition to the other diseases which may 
simulate tubercular meningitis should be mentioned nephritis, in which 
the symptoms of uraemia simulate, to a certain extent, those of tubercular 
meningitis. The urine should always be examined in doubtful cases of 
this kind. When uremic symptoms resulting from nephritis are present 
the disease will be shown by such examination, and we are thus able to 
differentiate it from tubercular meningitis. 

(8) From Epidemic Cerebrospinal Meningitis. — It is often quite difficult 
to differentiate the early stages of tubercular meningitis from those of 
cerebro-spinal meningitis. In typical cases, however, the diagnosis is not 
difficult, as the long prodromal period of tubercular meningitis, as a rule, 
does not occur in cerebro-spinal meningitis. The temperature in the latter 
disease is high in comparison with the former, in which it is moderate. In 
fact, all the symptoms of cerebro-spinal meningitis are markedly acute in 
comparison with those of tubercular meningitis, which is essentially a dis- 
ease of a subacute character. The sudden onset, extreme hyperesthesia 
and sensitiveness to sound, intense headache, and marked tenderness on 
pressure over the spine, so common in cerebro-spinal meningitis, are 
seldom met with in the tubercular form. The absence of leucocytosis 
points strongly to tubercular meningitis ; if leucocytosis is present, it is 
of little value in the differential diagnosis. The presence of iodophilia and 
leucocytosis points strongly to cerebro-spinal or acute septic meningitis as 
against a tubercular meningitis. 

(9) From Acute Meningitis. — The symptoms of meningitis in general 



SPECIFIC INFECTIOUS DISEASES. 415 

can, in the great majority of cases, be differentiated from other diseases, 
provided that we do not attempt to make the diagnosis too early. 

Having determined that the disease is of cerebral origin, we must 
next differentiate between the tubercular and the other forms of menin- 
gitis by means of the broad rules of which I have just spoken, and which 
I have condensed and simplified by means of the following table : 

TABLE 61. 
Cerebral Meningitis. 
Acute Form. Tubercular Form. 

Usually secondary (possibly primary). Secondary. 

Not hereditary. Hereditary. 

Acute. Subacute. 

Prodromata short, if any. Prodromata long, decided. 

Headache severe at once, with delirium early, Headache less severe at first, but gradually 

and soon followed by somnolence. increasing ; delirium less common and 

milder. 

Photophobia extreme. Photophobia not so marked. 

Convulsions violent. Convulsions less violent. 

Temperature high. Temperature moderate. 

Pulse and respiration rapid. Pulse and respiration slow and irregular. 

Duration short. Duration long. 

Cerebro-spinal fluid turbid, with preponder- Cerebro-spinal fluid less turbid, with pre- 

ance of polymorphonuclear cells. ponderance of lymphoid cells. 

Leucocytosis present. Leucocytosis sometimes present, often absent. 

Iodophilia present. Iodophilia absent. 

Presence of specific organism in the cerebro- Presence of tubercle bacillus in cerebro-spinal 

spinal fluid. fluid. 

Transudation into the ventricles may occur in either form. The younger the infant the 
nearer the two forms approach each other in the similarity of their symptoms. 

Prognosis. — When we are sure of our diagnosis, I believe that in our 
prognosis we should give no hope of recovery whatever, except that in 
extremely rare cases a temporary remission may take place. The reported 
cases of absolute recovery from tubercular meningitis cannot but be looked 
upon with scepticism. Indeed, the acute forms of meningitis simulate the 
tubercular so closely that without post-mortem verification recoveries can 
be supposed to be possible, but can hardly be accepted as proved. 

Treatment.-— The treatment of tubercular meningitis up to the time 
when the diagnosis is established should be purely symptomatic ; later we 
should make the child comfortable by every means in our power. As no 
case of tubercular meningitis has ever been proved to be cured by iodide 
of potassium or any other drug, it is useless and unwise to encourage 
ourselves and the parents by false hopes of good results arising from the 
administration of any drug whatever. Up to the present time our knowl- 
edge of the disease justifies us only in using drugs as palliatives for the 
child's suffering. 

The following cases illustrate the different phases of tubercular menin- 
gitis. The first case illustrates a type of disease such as may occur in 
the first year of life : 



416 PEDIATRICS. 

A male infant, ten months old, had always been well and strong. For a few days 
before he was seen he had been rather dull and feverish, but had shown no other ab- 
normal symptoms. He was evidently cutting some teeth at that time. On the day I 
saw him, except that he was somewhat fretful and put his hands to his mouth as 
though his gums were disturbing him, he seemed very well, and careful physical exam- 
ination revealed nothing abnormal in the ear, throat, chest, or abdomen. On the day 
following rny visit the slight symptoms of indisposition which he had previously shown 
disappeared, and he played with a toy whistle, blowing it himself, and seemed to be 
very well. This condition lasted for two or three days, when he became stupid and un- 
conscious, and about the tenth day from the time he first came under my observation he 
died in convulsions. 

This case should impress upon us the difficulty of making a diagnosis in the early 
period of a tubercular meningitis, and how guarded we should be in giving a prognosis 
in young infants, even when the character of the disturbance is very slight. 

The next case illustrates a tubercular meningitis occurring in a child 
two and a half years of age : 

The history of the case showed that the father's mother and the mother's mother 
and brother had died of consumption. When the patient was one year old he had 
measles ; otherwise he had always been well. About two or three weeks before he was 
first seen it was noticed that the child slept more than usual. At that time he appeared 
to be feverish, his tongue was coated, but there was no nausea nor vomiting. A few 
days later he vomited once or twice during the day. The bowels were constipated. 
Eight days before entering the hospital he had a slight convulsion, and three days later 
he cried a great deal, as if in pain. Two days before entering the hospital he had a 
number of convulsions during the night, each lasting about ten minutes. On the fol- 
lowing day the convulsions recurred. On the day he entered the hospital he began to 
have convulsions at three o'clock, which lasted about two and a half hours. At that time 
he was noticed to have marked internal strabismus of the left eye and slight strabismus 
of the right eye. The muscles of the neck were somewhat contracted. There was no 
paralysis of the extremities. 

The pupils were equal, reacted to light, and were somewhat dilated. The con- 
junctivas were injected, the left one especially so. Sensation was not impaired. The 
knee-jerks and ankle-clonus were absent. There was a marked tache c'er'ebrale. The 
respirations were irregular and sometimes of the Cheyne-Stokes type. The child was 
unconscious and very pale. The heart's action was very rapid, sometimes as high as 200 
beats in a minute. No souffles were detected. The temperature was 38.3° C. (101° 
F.). During the next day the child lay in a state of stupor. He continually moved the 
left forefinger and thumb, kept drawing the head to the left, and was very restless. He 
was reported to have cried all night and to have put his hand to his left ear. He lay 
with his eyes wide open, took nourishment well, and had less strabismus than when he 
entered the hospital. On the following day (about the thirteenth day of the disease) he 
became very restless, had sordes on the teeth, and his tongue was very dry. Examina- 
tion of the ears showed nothing abnormal. The abdomen was somewhat retracted. 
The bowels were moved regularly, and the movements appeared to be well digested. 
He took about 90 c.c. (3 ounces) of milk every two hours. On the following day there 
was no especial change, except that the muscles of the neck were firmly contracted and 
the tache cerebrale came out more slowly than on the previous day, A slight paralysis 
of the left side of the face appeared on this day. The left eyelid moved rather slowly, 
and the left corner of the mouth seemed to drop a little. The pulse was irregular, of 
fair strength, and intermittent. He did not take his nourishment so well. 

The comatose condition and other signs continued without improvement. The face 



SPECIFIC INFECTIOUS DISEASES. 



417 



became cyanotic, the respirations Cheyne-Stokes in character, the pulse irregular and 
intermittent. The temperature gradually fell until it was 37.2° C. (99° F.) in the 









CHART 


8. 








Days of Disease 


F. 


10 


11 | 12 


J3 


14 


15 


16 


17 | 


r CJ 


107° 
106° 
105 = 
104 ° 
103° 
102 = 
101° 
100 D 
99 3 

NORM'L 
TEMP. 

93 3 
97° 

96° 

95 D 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 1 


41. 6 C 

41.1° 

40.5° 

40.0° 

39.4° 

38.8 = 

33.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5 s 

35.0° 
































/ 
















/ 
















/ 














/ 
















/ 






^ 


,/ 


f\ 


/ 




/ 












/ 




/ 





































































Tubercular meningitis. Male, 2% years old. 



morning of the sixteenth day of the disease, when it began to rise rapidly until it 
reached 41.1° C. (106° F.)in the evening of the seventeenth day. when the child died. 

The autopsy showed the following lesions : 

Heart. — The right ventricle was dilated and the valves were normal. 

Lungs. — A number of small, flattened, gray masses were found in the pleura ; on 
section they were found to be miliary tubercles. Ther ight lung was adherent to the 
parietal pleura by strong fibrinous adhesions, beneath which were miliary tubercles, 
especially in the areas covering the ribs, the diaphragm, and the upper third of the 
sternum. A small number were also found in the substance of the lung. The bron- 
chial glands were enlarged, one of them being 1.2 cm. Q inch) in diameter. This 
gland on section was yellow and somewhat broken down. 

Spleen. — The spleen was of about normal size and showed many flattened miliary 
tubercles. Beneath the capsule, on section, there were found numerous tubercles of 
varying size : the larger ones were yellow and the smaller ones gray. 

Peritoneum. — There were found scattered all through the omentum, on the surface 
of the root of the mesentery, over the bladder, and particularly on the under sur- 
face of the right side of the diaphragm, numerous miliary tubercles. The lymph- 
glands of the mesentery were considerably enlarged, particularly beneath the stomach. 
Cki section they showed tubercles, most of which were quite large and had yellow, 
cheesy centres. 

Intestine. — In the intestine about the ileo-caecal valve there were several small 
ulcerations apparently in the process of repair. In the caecum there were two narrow 
ulcers about 1.5 cm. (f inch) long. The bases were injected. The walls were not 
broken down. 

Liver. — Many rather large tubercles were found beneath the capsule of the liver. 
They were flat, but not cheesy. 

Brain. — The convolutions of the brain were flattened. There was marked fibrino- 
serous exudation at the base of the brain, covering the optic commissures and the ad- 

27 



418 PEDIATRICS. 

joining parts. The third nerve was chiefly injected. Many small tubercles were 
present in the fissures of Sylvius and over the convexities of the brain. In the right 
half of the cerebellum, just beneath the pia, about the centre of the base, was a yellow 
nodule about 6 mm. (£ inch) in diameter. In the left lateral ventricle anterior to the 
velum interpositum was a similar nodule about 3 mm. (| inch) in diameter projecting 
into the ventricles. Both ventricles were moderately dilated by the serous fluid. The 
ependyma was everywhere granular : this condition was due to small, gray, transparent, 
tubercles. No tubercles were found in the third or fourth ventricles. 

Kidneys. — The kidneys contained a few rather large grayish areas with here and 
there a yellowish speck. 

The pathological diagnosis of the case was — 

Old tubercular ulcers of the intestine ; chronic tuberculosis of the mesenteric and 
bronchial lymph-glands ; solitary tubercle of the brain ; miliary tuberculosis of the pia,. 
lateral ventricles, pleura, lung, spleen, kidney, peritoneum, and liver. 

Another case was that of a boy three years old. 

There was no history of tubercular or syphilitic disease in the parents. Three 
weeks before entering the hospital, the child, who had previously been healthy, began 
to complain of pain in the abdomen, anorexia, and general malaise. Somewhat later 
it was noticed that the eyes would at times turn inwards and that the head would be 

Pig. 105. 






Tubercular meningitis. Male, 3 years old. 

drawn back. He was in this condition for two weeks before entering the hospital. On 
March 13 he was brought to the hospital, and was found to have a temperature of 38. 4 0, 
C. (101.2° F.), a pulse of 120, not intermitting, and respirations 40. He was in a stupid 
and drowsy condition. His head was drawn back, and he would not lie on his back. 
The tongue was not coated. An examination of the heart, lungs, and urine showed 
nothing abnormal. An examination of the eyes showed the pupils to be dilated, but 
equal in size and reacting to light. There were internal strabismus of both eyes, an 
optic neuritis, and the beginning of an atrophy following the neuritis. The patellar 
reflexes were absent, and there was no ankle-clonus. The superficial reflexes were 
normal. There was no tenderness of the head or spine. An examination of the ear 
showed nothing abnormal. On March 16 he showed nystagmus with conjugate devia- 



SPECIFIC INFECTIOUS DISEASES. 419 

tion to the right or to the left, according to the side on which he lay. No tache cerebrate 
was present. On the 17th an erythematous congestion was noticed on the right cheek, 
and he became still more somnolent. On the 18th the head was much less retracted. 
He had vomited once during the night and once in the morning. On the 21st he had 
a convulsion, which was the first that had occurred during the course of the illness. 
He was also found to have partial opisthotonos. The legs did not participate in the 
contraction, but the head was drawn back almost to the buttocks. His respirations 
became Cheyne-Stokes in character. On the same day he had four or five convulsions, 
and remained in a condition of opisthotonos in the intervals between them. These 
convulsive attacks lasted about half a minute each, and the intervals between them 
were about four minutes. There was incontinence of urine and of faeces. The pulse 
was rapid and irregular, and the extremities were cold. The tache cerebrate was ob- 
tained for the first time, and lasted for twelve minutes. 0.12 gramme (2 grains) 
of chloral and 2 grammes (h drachm) of brandy were given subcutaneously. The 
convulsions ceased, the opisthotonos disappeared in twenty minutes, and the child re- 
mained quiet. 

On the 26th the record was that for two days the child had been decidedly better, 
the retraction and strabismus were less, the nystagmus had disappeared, and he had 
recognized and spoken to his father. The tache cerebrate could be obtained, but was 
less distinct, and the temperature was normal. On the 28th he became worse again. 
His head was again retracted, but he was not wholly unconscious. There was reten- 
tion of urine, for which he had to be catheterized. On the 29th he had a convulsion 
lasting three minutes, in which the right arm was jerked up over his head. This was 
followed by partial opisthotonos, and then by a general convulsion lasting two or three 
minutes, during which his eyes rolled up. At times he would have convulsive move- 
ments and tremor without actual convulsions. This condition continued for nine days. 
He remained unconscious, with his eyes open and staring, the head drawn back, the 
abdomen retracted, and the tache cerebrate very marked. The respirations were of a 
pronounced Cheyne-Stokes type, and the pulse intermittent. The temperature varied 
from 37.2° to 38.8° C. (99° to 102° F.), but rose within the last twelve hours to 40° 
C. (104° F.), indicating that the fatal issue of the case was very near. 

On the following day there were a number of convulsions occurring in rapid suc- 
cession, especially involving the left side. These convulsions continued for five hours 
before the child died. 

The following case illustrates very well the tubercular meningitis of 
middle childhood : 

A boy, five years old, had always been well and strong. On December 3, while 
endeavoring to climb into bed, he fell and struck the back of his head. He cried 
afterwards, but the blow left no mark, and nothing was thought of it. The following 
day, while playing, he fell again and struck the back of his head, but the blow did 
not appear serious. Two days later he was unable to eat and was somewhat fretful, 
both of which conditions were unusual for him. 

On December 29 he had a slight follicular tonsillitis. His pulse and temperature 
were normal, the cheeks were flushed, the eyes dull, and the pupils normal. His 
head was slightly hot, and he was dull and drowsy. His bowels, which had been 
constipated, on the third day were moved by means of medicine. He continued to 
be in about the same condition until January 2, when his temperature was 37.2° C. 
(99° F.), and his pulse 64, regular and strong ; his face was flushed, and his eyes 
wpre vacant and staring. He vomited once on that night, passed his water involun- 
tarily, moved his left leg spasmodically, and clinched his hands occasionally. He was 
evidently uneasy, and moaned a good deal. On the folloAving day the pulse was occa- 



420 PEDIATRICS. 

sionally intermittent. In the mean time he became more and more drowsy, and 
finally relapsed into a state of unconsciousness. 

On the 3d of January the pupils were normal, but he was completely uncon- 
scious. The temperature was 38.1° C. (100.6° F.), the pulse 180, and the respira- 
tions 30. I saw the child on January 4, and on making a careful physical examination 
found nothing abnormal, except a slight congestion of the ear in the neighborhood of 
the malleus, and in the back over the apex of the lung was a slight elevation of pitch on 
percussion. The temperature was 39.1° C. (101.2° F.), and the pulse was 89 and 
strong. There was considerable twitching of the arms, chiefly on the right side, lasting 
from ten to twenty minutes. The pupils were slightly contracted, but were equal. 
That night he drew his right hand across the face with a quick trembling motion, the 
right leg being drawn up and the whole body trembling ; occasionally there was moan- 
ing and sighing respiration. 

The examination of the ears showed that there was a slight congestion in the 
posterior canal of both ears and also in the neighborhood of the right malleus. Both 
membranse tympanorum were clear, normal, transparent, and without injection of the 
manubrial blood-vessels. There was, in fact, no evidence of disturbance of the ears. 
On the posterior wall of each external auditory canal at the anterior third, more pro- 
nounced in the right than in the left ear, was a circumscribed patch of injection such 
as is observed in cases of inflammatory processes in the mastoid antrum, and occa- 
sionally in uncomplicated congestion of the middle ear. 

During the next few days the boy's condition varied but little. The eyes, usually 
closed, would at times open completely, when the eyeballs could be seen to move from 
side to side. The respiration was sighing, interrupted, occasionally almost inaudible, 
and then for a time noisy. At times the breathing was suspended for several minutes, 
when bright red spots would appear on the cheeks ; these would disappear when the 
respiration was resumed. The patient moaned occasionally, and there was some 
twitching and moving of the extremities, but no convulsions. The pulse was fair in 
strength, but at times intermittent. The temperature varied, but was moderate in 
degree. 

The extremities of the right side were absolutely motionless, and sensation was 
apparently absent. The child lay, as a rule, perfectly quiet, as though asleep, and at 
times would present the picture of a perfectly healthy child sleeping. 

On January 9 the extremities became cold, the face very pale, and the pulse im- 
perceptible. This condition lasted fifteen minutes, when he improved in appearance. 
During the night the breathing grew very rapid, he was restless, moved the left arm 
continually, and moaned. After some time he opened his eyes, looked around the 
room, and then became quiet and slept. The next day he was slightly unconscious, 
and the fingers were flexed, with a very strong contraction of the muscles. The breath- 
ing then became more difficult, the nostrils being widely dilated with every breath. 
During the night he was conscious for some time, swallowed water without difficulty, 
and the eyes were wide open. 

On January 1 1 there was ptosis of the right eyelid. The pulse became regular, 
compressible, and intermittent. The left arm was occasionally raised to the head with 
a quick spasmodic motion, the child moaning as if distressed. Later the eyes became 
fixed, the pupils dilated, the nostrils expanded, and a bluish color appeared around 
his mouth and nose. The breathing became very difficult. During an attack of this 
kind he had every appearance of being moribund, and each attack was thought to be 
his last. 

The change from day to day in the child's general condition was almost impercep- 
tible. He was, however, gradually becoming emaciated. 

On January 12 the pupils of both eyes were much dilated ; the right eye was al- 
most motionless, with ptosis of the right lid, while the left eye moved occasionally from 



SPECIFIC INFECTIOUS DISEASES. 421 

side to side in a circle. The face was livid, and the hands were mottled with bright 
red spots. Later, the left eye became quiet and showed a slightly contracted pupil. 

On the following day, January 13, the movements of the left eye were repeated, 
the right pupil being dilated, while the left one was contracted. During all this time the 
enemata were retained, the bowels moved regularly, and the urine was passed normally. 
The pulse was so weak that at times it could not be found at all at the wrist, and the 
breathing was at times inaudible and almost imperceptible. 

On January 17 there was slight discharge of pus from the mouth, and also from 
the left eye. During the next day his breathing grew more and more difficult, and it 
seemed as though he could not possibly live much longer. In the evening, however, 
his respiration was much easier and his whole appearance had greatly improved. His 
breath was very offensive, and there was a loud bubbling sound in the throat. 

On January 19 the right nostril was much more dilated during inspiration than 
the left. The forehead was shiny and slightly (edematous, and the veins were plainly 
mapped out. Occasionally he moved his right hip-joint and shoulder, which had been 
motionless for days. There was another slight discharge of pus from the mouth, and 
when his lips were wiped he seemed more sensitive to touch than before. During 
the night his left arm and left leg were constantly moved, and he moaned as though 
he were still in pain. His forehead was still cedematous. 

During the next day he was in a state of deep coma for four hours. He then 
drew a deep sigh and seemed somewhat conscious. The pulse was soft, intermittent 
and fluctuating. 

On January 20 he partly opened and shut his right eye, which was very sensitive 
to light. The breathing was difficult and noisy. The face was covered with perspira- 
tion. At 10 p.m. the sighing respiration began again, and at 10.15 he died quietly, 
on the thirty-first day of the disease. 

The autopsy was made eighteen hours after death and showed tne following patho- 
logical conditions : tubercular meningitis, acute hydrocephalus, ependymitis, tubercu- 
losis of the velum interpositum, tubercular nodules in the lungs, tuberculosis of the 
bronchial lymph-glands, tuberculosis of the spleen, tubercular ulcerations of the intes- 
tines. 

The following case (Fig. 106) simulated cerebro-spinal meningitis very 
closely, and illustrates an important fact, that a child may recover tem- 
porarily from an attack of tubercular meningitis and then die of a recur- 
rent attack. 

A child, twenty-one months old, was stated to have been healthy until it was nine 
months old. At that time it had a convulsion, which first affected the right and then 
the left side. It was unconscious for ten days, and was somnolent for four weeks. 
Two or three weeks later its general condition improved. During this time it did not 
use the muscles of its left side or limbs, and it could laugh only with the right side of its 
face. Its body was turned continuously to the left ; sensation was not interfered with. 
It gained slowly in strength, and the symptoms gradually disappeared, until it was thir- 
teen months old, when it seemed to be comparatively well, all motor disturbances having 
ceased. In the following months it had a few slight attacks of the same nature. The 
final attack from which it died occurred when it was twenty months old, and began 
with a convulsion on the right side with twitching of the muscles on the left side and 
frothing at the mouth. There was also ptosis of the left eye. It did not cry out when 
going into the convulsions, but had marked opisthotonos, which lasted, to a greater or 
less extent, for five weeks. During these five weeks it was unconscious, and there were 
several slighter attacks. 

On entering the hospital, physical examination showed that the child was of me- 



422 



PEDIATRICS. 



dium size, pale, poorly developed and nourished, and unable to stand, the left leg being 
weaker than the right. Nothing abnormal was found in connection with the heart or 
lungs. She could use her extremities partially, but there was an evident motor disturb- 
ance of the whole of the left side, and she took hold of objects with her right hand 
only. The index and little finger of the left hand were frequently found to be 
extended, the second and third fingers being flexed partially. There was also slight 
drooping of the left eyelid, and the lines of the left side of the face were obliterated. There 
was a very slight drooping of the left corner of the mouth. There was slight strabis- 
mus of the left eye, and an apparent lack of power of the left external rectus muscle. 
The patellar reflexes were exaggerated on the left side. Examination showed the ankle- 
clonus to be absent. The epiphyses of the wrists were somewhat enlarged. The 
child could not speak, and apparently could not understand readily. No evidence of a 
history of cerebral injury could be obtained. The circumference of the chest was 1 cm. 
(f inch) larger than that of the head. The cause of the disease was so obscure that at 
this period the diagnosis could not be definitely made, the supposition being that the 
child was suffering from the results of an attack of cerebro-spinal meningitis, or possi- 
bly from tertiary syphilis, or that a cerebral hemorrhage had taken place, with a result- 
ing spastic paralysis. 

While in the hospital the child presented a number of different nervous phenomena. 
At times she would appear to be for days semi-comatose and would not take notice of 
anything about her ; the eyes rolled up and she would have slight twitching of the 
body, but this was not localized, and there were no convulsions. At another time, 
while sleeping quietly during the night, she was found to be unconscious in the morn- 
ing, and to have her head slightly drawn back and her eyes turned up. Nystagmus 
was present, and the pupils were dilated and did not react to light, but were equal in 

Fig. 106. 




Recurrent tubercular meningitis. Female, 21 months old. 



size. Clonic twitching of the right foot and the muscles of the right side, flexion 
of the fingers of the right hand over the thumb, and twitching of the muscles of the 
wrist sometimes occurred. There was twitching of the fibres of the sterno-mastoid 
muscle on the right side. There was also twitching of the right side of the face. 
There was no spasm on the left side, except of the left sterno-mastoid, but there was a 
nystagmus of the left eye. These clonic twitchings were rhythmical and occurred 180 
times a minute. The pulse was 172, and was very feeble. The respirations were 80, 
rapid and rattling ; the temperature was 39.4° C. (103° F.). 

From 2 a.m. until 5 a.m. 0.36 gramme (6 grains) of chloral was given by enema, 
and 0.36 gramme (6 grains) of bromide of potassium was given every three-quarters of 
an hour by the mouth, alternating with the chloral. The spasms became less marked 



SPECIFIC INFECTIOUS DISEASES. 423 

after 3 a.m., but continued in a mild degree up to 11 a.m. During the remainder of 
the day and the next two days the child lay in a stupor, but had no convulsions. It 
was able to swallow brandy and milk, which were given to it by the mouth in small 
quantities at different intervals. 

On the next day she apparently had attacks of pain, when she would straighten 
herself out, throw back her head, and cry out. On the following day, she began to 
have the same twitchings as in the attack previously mentioned. They were of the 
same character, except that the extensor muscles of the left foot contracted feebly. 

On the following day it was reported that she had had no convulsions, but appa- 
rent attacks of pain, when she would cry out and throw her head back, and that she 
had had another attack of opisthotonos, which was so much more marked than before 
that the heels almost touched the back of her head. The next symptom which 
appeared was stupor. The temperature at this time was considerably elevated. 

On the following day there were no convulsions, and her condition was about the 
same as on the previous day, but the head was drawn back and was rigid, and the 
legs were drawn up and were held rigidly. She lay in this condition, most of the time 
in a stupor, crying out occasionally, and moving her left hand and arm more than she 
did the right. At times she would appear to be sleeping naturally and the rigidity 
would pass away 

The opisthotonos gradually become more marked and more frequent in its occur- 
rence, and, although the bowels were moved regularly every day, she took less nourish- 
ment, and the temperature continued to rise, and varied from 37.7° to 40° C. (100° to 
104° P.). 

During the last week of her life the opisthotonos became less marked, and at 
times passed away entirely. She opened her eyes, but the pupils reacted very slightly. 
The left pupil became somewhat larger than the right and reacted slightly, while the 
right pupil did not react at all. The spastic condition of the right wrist and left knee 
persisted, the patellar reflexes were equal and normal, and the child lay in a semi- 
stupor, with a temperature varying from 38.3° to 39.4° C. (101° to 103° F.). She 
took less and less nourishment, and had a slight cough. She gradually lost in weight 
and strength, and on the day before she died her respirations for a time were very 
rapid, running up to 100 a minute. Death took place apparently from exhaustion. 

The long duration of this last attack, embracing a period of eight or nine weeks, 
made the diagnosis very difficult. 

The autopsy showed the following pathological conditions : sunacute tubercular 
meningitis, chronic granular ependymitis, chronic hydrocephalus, atrophy of the brain- 
substance, miliary tuberculosis of the lungs, spleen, and kidneys, and chronic tubercu- 
losis of the lung. 

Some of the tubercular lesions were of recent growth, while others were evidently 
old ones and representative of a former attack. The presence of older tubercular 
lesions in the meninges, as well as of those which produced the symptoms in the last 
attack from which the infant died, proved that the case was one of recurrent tuber- 
cular meningitis. 

These cases of recurrent tubercular meningitis are so very rare, as the 
disease is so uniformly fatal in the first attack, that another case of this 
kind is given : 

A girl, five years old, entered the Good Samaritan Hospital with hip disease on the 
left side and dorsal Pott's disease. She was treated in bed and did very well for a time, 
but on May 7, after a week in which she showed anorexia and loss of weight, she be- 
gan to vomit, and on the following day complained of headache and photophobia. 
She rolled her head from side to side. Her bowels were constipated, and could not 



424 PEDIATRICS. 

be moved by enemata, and her abdomen was much retracted. This continued for four 
days, with at times delirium, accompanied by marked drowsiness. There were also 
ptosis of the left eyelid, slight convulsive movements of the limbs, and frequent move- 
ments of the hands to her head, as though she were in pain. On May 12 she had 
recovered so much that she played with the other children and called for her books 
and toys. The left pupil, however, remained a little smaller than the right. On the 
15th of May, and again on the 20th, 21st, 25th, and 27th, the patient became drowsy, 
and complained of headache. In the intervals between these attacks she seemed 
bright and well. During the drowsy periods her abdomen was retracted and her 
bowels were constipated. 

From the 27th of May until the 20th of July she appeared as well as usual. On 
the latter date her temperature suddenly rose to 40.1° C. (104.2° F.). She had pain 
in the head and photophobia, and the right pupil was larger than the left. This lasted 
only two days. She then became bright and well again, and continued so for over ten 
weeks. On October 2, having been perfectly well on the previous day, she began to 
vomit and to complain of headache. Two days later she fell into a stupor and became 
completely comatose. On October 6 the left pupil was widely dilated and the right 
one was contracted to the size of 2 mm. (& inch) ; there were convulsive movements, 
and later in the day she died. 

The post-mortem examination showed a recent tubercular meningitis. In addi- 
tion to these lesions there were found some older large tubercles of the brain and the 
remains of the previous attacks of tubercular meningitis. No lesion of importance 
was detected in the other organs. 

It is not unusual to meet with a tubercular meningitis secondary to 
tubercular disease of the spine. This complication occurred in the fol- 
lowing case in a child four years old : 

The child was being treated for Pott's disease with lateral deviation of the 
spine. He was placed on a frame for five weeks, and at the end of that time he lost 
in appetite and weight and began to have a cough. Nothing especial, however, was 
found in the lungs. The bowels became constipated, and he then began to have 
some mental disturbance and to vomit. A few days later he became unconscious, and 
on examining him his pupils were found widely dilated, uneven, and not responding 
to light. His temperature was usually about 38.8° C. (102° F.). The pulse and 
respirations were somewhat quickened. His head was retracted, and on the day of 
his death he had a convulsion. 

Tubercular meningitis may also occur in connection with disease of the 
hip, the latter being much more common than when the spine is affected. 
The following case illustrates this complication : 

A child, four years old, was being treated by an irregular practitioner for disease 
of the hip-joint. The child had been allowed to drag itself about, and the treatment 
had been with drugs and not by apparatus. When the child was placed under Dr. 
Brown's care he had him taken to the country and placed in a house and room where 
all the hygienic surroundings were good. He kept the child in bed and treated it by 
means of the method of extension usually employed in these cases. The child at first 
began to improve, but after a few weeks lost in weight and in appetite. Its tempera- 
ture, which had been varying from 37.2° to 37.7° C. (99° to 100° F.), rose to from 
39.4° to 40° C. (103° to 104° F.). A few days later the child became somnolent and 
had convulsions. 



PLATE VI. 








Tubercular Meningitis. 



SPECIFIC INFECTIOUS DISEASES. 



425 



When I saw the case with Dr. Brown it was evidently one of tubercular menin- 
gitis, apparently secondary to disease of the hip-joint, and the child died within twenty- 
four hours after I had examined it. 

The tubercular form of otitis is not uncommon, and it may be the 
starting-point for tubercular meningitis. Surgeons should, therefore, 
watch carefully the possible complication of tubercular meningitis when 
treating tubercular disease of the bones and joints and of the ear. 

The following case was one of tubercular meningitis, associated with 
an acute miliary tuberculosis, occurring in my wards at the Children's 
Hospital. The pathological appearances on the base of the brain, as 
shown on autopsy, are represented in Plate VL, facing page 424. 

The child entered the hospital on September 13. She was three years of age. 
With the exception of an attack of whooping-cough she had been well until two weeks 
before entrance, when she was taken with vomiting and diarrhoea. She complained of 
headache and pain in her stomach, and there had been continuous fever. The diarrhoea 
lasted a few days, and she then became constipated. Four days before entrance the 
muscles of her neck became stiff. No further history could be obtained. 



CHART 9. 



CHART 10. 



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Tubercular meningixis. Age, 3 years. 



Tubercular meningitis. Age, 2 years. 



The physical examination showed the child to be well developed and fairly nour- 
ished, but anaemic. She lay in a stupor most of the time, but could be aroused. The 
pupils were equal and reacted sluggishly. The tongue was coated, the throat, heart, and 
lungs showed nothing. The head was slightly retracted, and the posterior muscles of 
the neck were rigid. The abdomen was not retracted, and nothing abnormal was de- 
tected. A tache cerebrate was present. The knee-jerks were normal. Babinsky's 
sign was present in both feet, and Kernig's sign was also obtained. 



426 PEDIATRICS. 

On September 14 there were some convulsive movements of the right extremities, 
and breathing was somewhat labored. 

On September 15 the child took her food very poorly, and could not swallow well. 
There were convulsive movements, but no general convulsion. 

On September 16 the legs were rigid and held in extreme extension most of the 
time. The pupils were unequal and dilated, and did not react to light. 

On September 17 strabismus of left eye developed, but was not constant. There 
was convulsive twitching of the limbs, with rigidity most of the time. The face was 
flushed, perspiration was very free, and the abdomen was somewhat distended. 

On September 18 the condition remained the same, except for the additional symp- 
tom of Cheyne-Stokes respiration. The rectal feedings were not retained, and it was 
impossible to insert a catheter for nasal feedings, owing to the swollen condition of 
the mucous membrane of the nares and the difficult breathing. 

On September 21 the respiration had become more sighing in character. The 
child perspired very freely. The white blood count was 8000. 

On September 22 the condition, which had remained practically the same, except 
for the rising temperature and accelerated pulse, became worse. The child seemed to 
grow weak rapidly, and the respirations and pulse became irregular and the child 
finally died. Chart 9, page 425, shows the course of the temperature. 

Lumbar puncture was performed immediately after death, and a slightly cloudy 
fluid with flecks of fibrin was obtained. 

The autopsy showed the original focus to be in a bronchial lymph-gland, which 
was enlarged and caseous, with a cavity at the centre. There were found miliary tuber- 
culosis of the lungs, liver, spleen, and kidneys, tubercular meningitis, and tubercular 
bronchial glands. The brain weighed 1080 grammes. At the base, around the pons, 
and in the fissure of Sylvius there was a yellow, gelatinous material, while along the 
blood-vessels of the pia were scattered numerous miliary tubercles, sometimes single 
and again confluent. 

The following was a case of tubercular meningitis with symptoms of 
comparatively short duration and associated with a general miliary tuber- 
culosis. It is especially interesting in that the tubercular process, as shown 
by the autopsy, and as represented in Plate L, frontispiece, was most 
highly and typically developed on the convexity of the brain instead of at 
the base, as is generally the rule. 

The child was two years old. She had been losing flesh and strength for about 
two months. Two weeks before entering my hospital wards she was taken with 
vomiting without special reference to the taking of food. This was the only symptom 
the parents noticed until three days before entrance, when convulsions and fever de- 
veloped. Nothing more definite could be learned from the parents. 

The physical examination showed a child who was fairly developed and nourished, 
pale, pupils widely dilated, the right reacting sluggishly, and the left not at all. The 
eyes were rolled up, but there was no strabismus. The head was retracted, there was 
no tenderness along the spine. The tongue was slightly coated. There was a slight 
rosary. The throat, heart, lungs, and abdomen presented nothing abnormal so far as 
could be determined. There were no petechiae. A tache cerebrale was present. The 
knee-jerks were slightly exaggerated on both sides. The plantar reflexes were normal. 
Babinsky's sign was present in both feet. Kernig's sign was absent. The child lay 
in a stupor. The white blood count was 6000. 

On the following day there were convulsive twitchings of the right arm and right 
side of the face. On the third day after entrance these signs became more marked, 



SPECIFIC INFECTIOUS DISEASES. 427 

the respirations Cheyne-Stokes in character, the pulse rapid, irregular, and small. 
There were no convulsions of the entire body, but the right arm was flexed at the 
elbow. These symptoms continued until the fourth day, when the child died. The 
course of the temperature is shown in Chart 10. page 425. 

Lumbar puncture, done immediately after death, gave a slightly turbid fluid, and 
flecks of fibrin separated out. No tubercle bacilli were discovered in the sediment from 
lumbar puncture. 

At the autopsy the following condition of the brain was found : 

The dura was tense and bulging ; the superior longitudinal sinus was normal ; 
the gyri were flattened ; the sulci were partly obliterated ; the vessels of the pi- 
arachnoid over the vertex were markedly injected, and the cerebro-spinal fluid consid- 
erably increased. In the pia mater over the superior surface of the right frontal lobe, 
and extending to the mesial surface, was an area 5 by 3 cm., with opaque, grayish- 
yellow, single and conglomerate tubercles ; the single tubercles averaging one mm. in 
size. Tubercles were present in great numbers in the sulci, adjacent to the blood-vessels, 
but were also distributed upon the gyri over both hemispheres, but especially over the 
lateral surfaces of the parietal lobes. About the optic chiasm and interpeduncular 
spaces was a mass of semi-opaque gelatinous material beneath the turbid pia. Around 
the branches of the middle meningeal artery, and especially in the Sylvian fissure, was 
an abundant diffuse fibrino-purulent exudation. Scattered tubercles were found over 
the base, but in less numbers than over the vertex. Many were scarcely visible, being 
nearly transparent and less than a millimetre in diameter. 

The anatomical diagnosis was : tubercular meningitis, acute miliary tuberculosis 
of the lungs, tubercular ulceration of the intestines, tuberculosis of the mesenteric 
lymph-nodes, and a mild degree of rhachitis. 

TUBERCULOSIS OF THE JOINTS. 

Tubercular disease of the joints is essentially a disease of childhood; 
it is rarely congenital, and under one year is not common. In 1344 
cases of hip disease, 1000 occurred under fifteen years of age. (Bradford 
and Lovett.) In hip disease, for example, a series of cases from the New 
York Dispensary showed that 115 occurred under three, 316 from three 
to five, 509 from five to ten, 140 from ten to fifteen, and 98 over fifteen 
years. This may be taken as fairly representative of the general liability 
to the diseases at different ages. 

At the Children's Hospital, Boston, from 1869 to 1893, 3820 cases of 
tuberculosis of the joints were as follows : 

TABLE 62. 

Spine 1964 

Hip 1402 

Ankle 300 

Knee 104 

Wrist 20 

Shoulder 15 

Elbow 15 

These figures are similar to those reported by other American 
authors. 

With regard to the causation of tubercular disease of the joint, it may 
be stated that che element of heredity is to be found in a large proportion 
of cases, which is variously estimated, the percentage, according to differ- 



428 PEDIATRICS. 

ent authors, varying from twenty-four (Croft) to sixty-eight (Gibney) ; an 
average estimate would perhaps be forty per cent. (Nichols). 

Traumatism is accepted as being the cause of chronic disease of the 
joints in certain cases (Konig) ; this percentage, also, is variously estimated 
from thirty- five to fifty per cent. Chronic tubercular disease of the joints 
follows in certain cases after the' exanthemata, especially measles and 
scarlet fever. 

Pathology. — Tuberculosis of the joints in children, as well as in 
adults, is now much more uniformly regarded as being of bony origin 
than was formerly supposed. 

The existence of a primary synovial tuberculosis in children must be 
regarded as extremely rare, and only to be demonstrated by the examina- 
tion of all parts of the bones entering into the formation of the joint. 
Finding a tuberculosis of the synovial membrane at operation, with an ob- 
vious bony lesion, cannot be accepted as proof of primary synovial disease. 

The original statement of Volkmann is, " The fungous inflammation of 
the joints in children and adults begins generally not at all as an arthrop- 
athy, but as a pure osteopathy, with a very circumscribed condition of 
tubercular osteitis.' 1 

Nichols, in the examination of one hundred and twenty tubercular 
joints from children and adults, did not find one joint where, if all the 
bones entering into the joints were sawed open in thin layers, one or 
more old bone foci were not found. 

The process by which joints become affected by tubercular disease is 
as follows : A tubercular focus develops in the spongy tissue of the bone 
near the epiphysis, and by an extension of this process the bone is de- 
stroyed in the line of least resistance, which is usually towards the sur- 
face of the joint. When perforation of the joint by this focus occurs, the 
tubercle bacilli obtain access to the joint cavity and a tubercular syno- 
vitis begins. From this point destruction in any direction is, of course, 
possible. Under favorable conditions of rest and separation of the surfaces 
of the joint by traction, in certain cases, nature tends to limit the process 
by repairing and replacing the tubercular tissue by the formation of fibrous 
tissue which grows into and replaces the tubercular material. The soft 
parts around the joint are, of course, secondarily affected, and abscesses 
are a frequent complication. 

The contents of a tubercular abscess may be sterile so far as pyogenic 
organisms are concerned, or they may contain, especially in their later 
stages, pyogenic organisms. Tubercle bacilli are to be found in these 
abscesses in only about one-third of the cases, and, as a rule, only after 
prolonged search. Inoculation experiments must be relied upon in the 
majority of cases to establish their presence. The presence of leucocy- 
tosis in a child with disease of a joint does not establish the presence of 
pyogenic organisms 

Symptoms. — Hip. — Chronic tubercular disease of the hip-joint, com- 



SPECIFIC INFECTIOUS DISEASES. 429 

monly known as hip disease, most often begins with lameness, paroxysmal 
cries at night, and a stiffness in the joint which is more noticeable in the 
morning than at night. The pain is more often referred to the knee than 
to the hip, and may be very severe or may be slight. 

On examination in the early stages, the joint is found to be somewhat 
limited in its motions, the trochanter is slightly thicker than the one in 
the well limb, and wasting of the muscles occurs in the thigh and the calf. 

The prognosis in early cases is excellent for the restoration of a useful 
limb, and even in the late cases the adoption of treatment by traction gen- 
erally brings about good results. It must, however, be remembered that 
these children are tubercular, and that a certain number of them develop 
tubercular meningitis in the course of the disease. 

Spine. — Chronic tubercular disease of the spine, or Pott's disease, 
begins usually with stiffness of the back and pain on exertion, which is 
in most cases referred to the peripheral end of the nerves, so that the 
pain may be complained of either in the abdomen or chest. Such chil- 
dren walk with a guarded gait and stiffly, and when tired support them- 
selves by leaning on furniture or by resting the hands upon the thighs. 

In the cervical region torticollis and difficult breathing at night may 
be the only symptoms. In the lumbar region one symptom generally 
noticed is an apparent lordosis, in which the child leans far backward. 
Paralysis, which occurs in a certain proportion of cases due to a pressure 
from meningitis originating at the seat of the disease, may be the first symp- 
tom ; it is accompanied by increased reflexes and a loss of power in the 
legs. Psoas abscess is a common complication in the lower part of the 
column, and the first symptom noticed in this complication is generally 
inability to hyperextend the leg upon the affected side. The chief sign 
to be relied upon in the diagnosis is stiffness in some part of the spine. 
This is most easily detected by having the child stoop to pick up objects 
from the floor, and by laying the child on the face and flexing the spine by 
lifting the body by the legs. The appearance of a knuckle occurs early 
in the disease, but it is most important that the diagnosis should be made 
before this knuckle occurs, or while it is still small. 

The prognosis is perhaps not so favorable as in hip disease, but in 
early cases the results are usually excellent, and even in late cases much 
is to be gained from accurate support to the spine. 

Knee. — Chronic tubercular disease of the knee-joint, or tumor* albus, 
is most often made evident by swelling of the knee of a chronic charac- 
ter, as a rule accompanied by pain. The child is apt to walk with the 
knee somewhat bent, and it is often difficult to fully extend it. Motion in 
the knee-joint is limited and the joint may or may not contain fluid. The 
character of the swelling is commonly that of a gelatinous mass involving 
the joint rather than a mass of fluid filling it. The occurrence of bony 
enlargement is most significant as probably establishing the existence of 
chronic tuberculosis. 



430 



PEDIATRICS. 



Fig. 107. 



In the diagnosis much difficulty is often experienced in determining 
between chronic disease and sprains. It may be said in general that 
chronic sprains in children are not very common, and that it is not wise 
to make such a diagnosis until after recovery has occurred. 

As to the prognosis, chronic tuberculosis of the knee-joint apparently 
runs a much less severe course than that of the hip or spine, and is most 
favorably affected by efficient treatment. 

Chronic tubercular disease of the other joints is characterized by 
swelling, more or less stiffness and pain, and such joints, as a rule, present 
the same symptoms as those described in speaking of the knee. 

Tubercular Dactylitis. — Tubercular dactylitis is a tubercular disease 
of the phalanges of the hand and foot. Usually, the cartilaginous ends 

of the bones are not affected ; the 
bone appears larger in diameter 
than is normal and is pyriform 
in shape. This enlargement is 
due to the increased size of the 
periosteum which forms a new 
layer of bone, and this new layer 
of bone may be very thin. Fre- 
quently the tubercular centre 
opens to the surface by one or 
several tubercular sinuses ; heal- 
ing in such cases may occur 
spontaneously, but operation in 
advanced cases is advisable. A 
permanent deformity may arise 
from the removal of the diseased phalanx. 

Fig. 107 represents a tubercular dactylitis of the third finger of the left 
hand of an infant. 

TUBERCULOSIS OF THE THYROID GLAND. 
Although tuberculosis of the thyroid gland may occur as a primary 
disease, it is exceedingly rare, the disease practically being always second- 
ary to a general miliary tuberculosis, and not presenting symptoms which, 
as a rule, can enable us to make a diagnosis during life. Amyloid de- 
generation of the thyroid gland may occur as the result of a chronic 
tuberculosis, especially of the joints. 

TUBERCULOSIS OF THE THYMUS GLAND. 
Tuberculosis of the thymus gland may occur in- general tuberculosis, 
but is never primary. 

TUBERCULOSIS OF THE PANCREAS. 
Tuberculosis of the pancreas may occur in general tuberculosis, but is 
never a primary disease. Amyloid degeneration of the pancreas may 
occur as a result of chronic tuberculosis, especially of the joints. 




Tubercular dactvliti? 



SPECIFIC INFECTIOUS DISEASES. 431 

TUBERCULOSIS OF THE SPLEEN. 

Tubercular lesions of the spleen are always secondary. They occur 

only in the form of small miliary tubercles. Amyloid degeneration of the 

spleen may occur as a result of chronic tuberculosis, especially of the 

joints. 

TUBERCULOSIS OF THE LIVER. 

Tubercular lesions of the liver are always secondary. They appear 
in the form of small miliary tubercles and cheesy nodules. Amyloid de- 
generation of the liver occurs in certain cases of tuberculosis, especially 
where there is wasting. Tuberculosis is not, however, a primary disease 
of the liver, but a symptom of tuberculosis elsewhere, especially of the 
bones and joints, and is not so common in children as in adults. Tuber- 
culosis of the liver occurs in connection with general tubercular disease 
of other organs, and does not in itself present any especial characteristic 
clinical manifestations. The rare instances in which large caseous masses 
cause obstruction and, later, disintegration of the tissues, with hepatic en- 
largement and abscess, are not usually recognized during life. 

TUBERCULOSIS OF THE KIDNEY. 
Tuberculosis of the kidney in children occurs in two forms : (1) As a 
miliary tuberculosis, the tubercle bacillus being conveyed into the tissues 
by the blood. This form rarely reaches any clinical importance. (2) As 
a tuberculosis beginning in the pelvis of the kidney and extending from 
this into the cortex. This form is by far the most serious in its symptoms 
and results. The detection of the tubercle bacillus in the urine in these 
cases is the only positive sign of the disease. The symptoms are those 
of a pyelonephritis represented by pus in the urine, an irritable bladder, 
and sometimes the presence of a tumor or abscess in the renal region. 
The treatment is essentially surgical. Amyloid degeneration of the kidney 
may occur as a result of chronic tuberculosis, especially of the joints. 

TUBERCULOSIS OF THE BLADDER. 
Tuberculosis of the bladder is very rare. 

TUBERCULOSIS OF THE TESTICLE. 
As compared with the frequency of its occurrence in adults, tubercu- 
lar disease of the testicle is rare in infancy and childhood. When the 
disease is present the gland is considerably swollen and often nodular, but 
rarely very tender. As the disease progresses adhesions may form with 
the tissues of the scrotum, and the degenerated material may be dis- 
charged through a fistulous tract. General treatment is indicated if the 
disease is just starting, but if it has already destroyed the usefulness of 
the gland it is safer to operate immediately and remove the focus of 
infection. Here, of course, we should be guided by the conditions, 
elsewhere. 



432 PEDIATRICS. 

TUBERCULOSIS OF THE SKIN. 

The cause of what is now known to be tuberculosis of the skin 
(lupus or scrofuloderma) was for many years unknown. It was desig- 
nated by various terms according to the different forms which it assumed 
on the skin. Thus, in one form it was called lupus, and in another 
scrofula. We now know that all these forms are caused by the same 
micro-organism, the tubercle bacillus, and that this bacillus may find 
its nidus in the skin, as it does in all other organs of the body, — that 
is, we may have a local tuberculosis of the skin. The disease does not 
differ in the child in its appearance, its course, and its general symptoms 
from that met with in the adult. As a rule, it causes, next to syphilis, 
the greatest destruction of tissue of any known disease of the skin. The 
time of its appearance varies, but it is more common in adults than in 
children. 

Treatment. — The treatment is the same as in adults. The funda- 
mental object to be obtained is the destruction of the diseased tissue. 
Where there is a small isolated area which can be easily removed by the 
knife, this method of treatment should be employed. W T e must remem- 
ber, however, that by this method it is almost impossible to avoid re- 
moving the sound tissue with the diseased, and that such good results 
as the avoidance of unsightly scars are not obtained so well by this 
method as by others. Therefore, when the tissues are extensively dis- 
eased, and areas are involved where it is desirable to avoid scarring, such 
as the face, a locality which is very frequently attacked by tuberculosis, 
the actual cautery and electro-cautery may preferably be used. Various 
caustics, as the solid stick of nitrate of silver, as recommended by the 
Vienna School, have been found of much value. This disease, under all 
circumstances, is very intractable to treatment, and often causes great 
deformity. 

EPIDEMIC CEREBROSPINAL MENINGITIS. 

Epidemic cerebro-spinal meningitis is a primary acute infectious disease 
caused by the diplococcus intracellularis, and characterized primarily by 
lesions of the piarachnoid of the brain and cord. 

Etiology.— The cases of cerebro-spinal meningitis which have occurred 
in Boston and its vicinity, including my own cases at the Children's 
Hospital, reported by me in 1895, have been so exhaustively treated by 
Councilman, and Mallory and Wright in the Report of the State Board of 
Health of Massachusetts for 1898, that in my description of the disease I 
must acknowledge at once my indebtedness to these investigators for the 
use which I have necessarily made of their work. 

As, for the first time in the history of the disease, the lesions have 
been studied from the stand-point of their bacteriology, this work should 
be taken as the standard by which we are to be guided in the study of 
the pathology, symptoms, diagnosis, and prognosis of the disease. 



SPECIFIC INFECTIOUS DISEASES. 433 

Cerebrospinal meningitis was first recognized and described by Vieus- 
seaux in Geneva in 1805. The first case which occurred in America was 
in 1809. The disease may occur in beasts as well as in man, and has 
been much more wide-spread and frequent in America than in Europe. 
It is rare in infancy, but is more common in children than in adults. 
The contagious nature of the disease is somewhat doubtful. There 
seems to be a high degree of immunity to a second attack. The incu- 
bation is unknown. The disease may be epidemic or sporadic. The 
mode of entrance of the organism is unknown, but may possibly be 
through the nose. 

Pathology. — Nervous System; Meninges. — The inflammatory process 
is characterized by purulent, sero-purulent, and fibrino-purulent exuda- 
tion, chiefly in the sulci along the vessels of the choroid plexus, and is 
usually most pronounced at the base, but at times is more marked on 
the convexity of the brain, especially over the parietal and occipital lobes. 
The meninges of the cerebellum are always affected. The meninges of 
the entire brain are rarely involved, although occasionally large areas are 
included in the inflammatory process. The longer the duration of the 
disease the more extensive are the lesions. In the very chronic cases 
oedema and general thickening of the meninges are the characteristic 
features of the lesions. 

The inflammation is confined chiefly to the piarachnoid ; the dura is 
but slightly involved, and the subdural space is increased by the fluid 
exudate. 

In the most acute cases, in which the macroscopic changes are very 
slight, the lesions are shown by microscopic examination to consist chiefly 
of purulent infiltration of the meninges, with injection of the blood- 
vessels. The polynuclear leucocytes are massed in some places, scattered 
in others, and with but little fibrin among them. The absence of eosino- 
philic cells is notable. There is no evidence of proliferation of tissue. 

In the more advanced cases, on the other hand, there are large num- 
bers of cells, chiefly polynuclear leucocytes, lying in the dilated lymph- 
spaces of the tissue. The presence of red blood-corpuscles is rare. The 
fibrin is present in considerable amount, often showing hyaline changes, 
but is never so great as in the meningitis produced by the pneumococcus. 
Large epithelioid cells, from two to eight times the diameter of a leuco- 
cyte, and filled with leucocytes, or rarely with lymphoid cells, are often 
seen, but their origin is obscure. The vessels are dilated, and at times 
contain thrombi. Proliferative changes within the intima of the arteries, 
which are common in tubercular or pneumococcus meningitis, are rarely 
found. 

In the acute cases the macroscopic and microscopic changes in the 
meninges of the cord are very similar to those of the brain. The cord is 
always somewhat affected, and occasionally to a greater degree than 
the brain. The injection of the dura is especially intense. The fluid in 

28 



434 PEDIATRICS. 

the subarachnoid space is greatly increased ; it is cloudy and contains 
flocculi of fibrin and pus. As a rule, the dorsal and lumbar cords are 
more extensively involved than the cervical portion. In the chronic 
cases the meninges of the cord show the same oedema and thickening as 
those of the brain. 

Brain and Cord Tissues. — Lesions of the tissue of the brain and cord, 
as a rule, cannot be determined without careful microscopic examination. 
They are more marked in the prolonged or chronic cases. They are 
represented chiefly by slight dilatation of the ventricles with cloudy fluid, 
by dilatation of the vessels of the ependyma and choroid plexus, and by 
an accumulation of pure pus or pus and fibrin in the posterior cornua of 
the lateral ventricles. The consistency of the brain-substance is gener- 
ally but little altered, but is softer than usual, owing to the oedema and 
dilatation of the ventricles. Sometimes areas of softening and punctiform 
hemorrhages may occur. All the blood-vessels of both the gray and 
white matter are injected. In the cord the congestion of the vessels and 
the diminished consistency of its tissue are the chief lesions. The cord is 
always less affected than the brain. Proliferative changes in the neuroglia 
are among the most characteristic microscopic lesions in the brain tissue, 
but are rarely found in the cord. Degenerative lesions in the ganglion 
cells are usually present, especially in the very chronic cases. 

Nerves and Ganglia. — All of the cranial nerves are affected, but the 
second, fifth, seventh, and eighth are most extensively involved. They 
are reddened, oedematous, and infiltrated with the purulent exudation 
which often follows the nerves to their foramina. The spinal nerves are 
also involved, and their roots lie embedded in the exudation. The spinal 
ganglia are injected and oedematous. Degenerative changes in the nerve- 
fibres are common. 

The inflammatory process may extend along the optic nerve and pro- 
duce a purulent inflammation of the orbit or eye ; by extension along the 
fifth nerve it may produce a degeneration or destruction of nerve-cells of 
the Gasserian ganglion, and by extension along the auditory nerve it may 
cause lesions of the internal ear, with or without acute inflammation of 
the middle ear. 

The Lungs. — The lesions in the lungs occurring in the course of an 
epidemic cerebro-spinal meningitis vary from a simple congestion with 
oedema to areas of broncho-pneumonia associated with general bronchitis, 
or there may be a characteristic croupous pneumonia due to the pneumo- 
coccus. In a certain proportion of cases the pulmonary lesions are due 
to the diplococcus intracellularis, which enters the lungs and produces a 
focal pneumonia characterized by especial anatomical conditions. Hemor- 
rhagic oedema is found in the periphery of the foci, which vary in size 
from that of a pea to large areas of consolidation, which closely resemble 
an acute croupous pneumonia, even to the presence of a fibrinous exuda- 
tion on the pleura. On section of such an area, numbers of irregular 



SPECIFIC INFECTIOUS DISEASES. 435 

grayish foci with softened centres and hemorrhagic and (Edematous tissue 
between them are found. The central areas represent a purulent infil- 
tration of the tissue with abscess formation. The foci of consolidation 
are not bronchial in origin. The infection of the lungs by the diplococ- 
cus is probably by means of the blood rather than of the bronchi, and 
may occur in almost any period of the disease. In all these cases im- 
mense numbers of diplococci are found within the pus-cells. 

Spleen. — The size of the spleen is generally smaller than in most of 
the acute diseases, although there is considerable variation. The increase 
in size is due chiefly to hyperaemia. There is very little change in the 
histological appearances of the spleen. 

Lymphatic Nodes. — There is usually no enlargement of the lymphatic 
nodes except in the complicated cases, and there are no microscopic 
changes beyond the injection of the blood-vessels. 

Liver. — The liver is usually pale and cloudy on section, and in some 
cases there is slight increase in the fibrous tissue with cellular infiltration. 

Kidneys. — The kidneys show acute, degenerative lesions in all cases, 
but a nephritis is rare if the meningitis is uncomplicated. 

Skin. — Lesions of the skin are rare ; when present, they are in the 
nature of ecchymoses with intense congestion of the surrounding vessels, 
and with some infiltration with pus-cells beneath the epithelium. 

In addition to the parenchymatous degeneration of the heart, liver, and 
kidneys, there are a certain number of other secondary lesions frequently 
met with, such as subserous, punctate hemorrhages in the endocardium, 
hyaline and granular degeneration in the voluntary striated muscles, occa- 
sionally multiple abscesses in various parts of the body, suppurative in- 
flammation of the joints, and choroiditis. 

The lesions are essentially the same in the epidemic and sporadic 
cases of cerebro-spinal meningitis. 

Types of the Disease. — There are certain types of epidemic cerebro- 
spinal meningitis which differ so markedly as to deserve special mention. 
The cases may be either acute or chronic. The acute cases are those in 
which active symptoms last for about fifteen days, and two other forms 
may be recognized, — the mild and the fulminating. 

Mild Form. — The mild form occurs more frequently in children than 
in adults. It has an acute onset, short course of one or two days, and 
rapid subsidence. These cases are sometimes called "abortive," but 
have not been verified as yet by lumbar puncture. 

Fulminating Form. — This term is restricted by Councilman to those 
cases which are fatal within forty-eight hours from the onset of the disease. 

Chronic Cases. — The chronic cases are those represented by less active 
onset, by remissions and exacerbations, and long duration. 

Intermittent Forms. — These cases are chronic in type, and are seen in 
those instances in which, with or without abatement of the other symp- 
toms, there are complete intermissions in the temperature. 



436 - PEDIATRICS. 

Symptoms. — The chief symptoms are those connected with the nervous 
system, such as vomiting, delirium, coma, paralysis, pain, retraction of 
the neck, opisthotonos, and the mental condition after the attack ; also 
those symptoms connected with the lung, with the skin, the eye, the ear, 
the nose, the throat, and the joints ; also the pulse and temperature, 
and the condition of the blood and spinal fluid. In some cases the onset 
is not so sudden, and difficulties have arisen in the differentiation from 
typhoid fever and pneumonia ; but, except in the rather rare meningeal 
types of these latter diseases, the diagnosis will in a few days become clear. 

In young infants the symptoms of cerebro-spinal meningitis may be 
merely a heightened temperature with clonic convulsions, so that the 
diagnosis cannot be made during life from the various forms of reflex 
convulsions which may occur at this age, and cerebro-spinal meningitis 
can only be suspected. General infection by the diplococcus intracellu- 
laris is unknown. The mild cases may subside in a few days ; the acute 
cases may last for a number of weeks, and are often fatal. Some cases 
are so very sudden and violent in their development that they resemble a 
general toxic infection, and rapidly prove fatal in even a few hours (fou- 
droyant). Some cases show decided intermissions in intervals of several 
days, during which the child seems much better, the temperature is nor- 
mal or slightly raised, and the pain and tenderness are much diminished. 
The symptoms then return. Marked emaciation occurs in these cases. 
In some cases after the usual acute onset, an intermission may come, of a 
much longer interval of weeks, as to the severe symptoms and the fever ; 
but the other symptoms are apt to continue, and the disease may assume 
a chronic form, lasting three or four months. 

Vomiting. — Vomiting is a very common symptom, and may from its 
constancy become a dangerous one. It may occur early or late in the 
disease, and is due to direct or reflex irritation of the vomiting centre, 
being regarded as of cerebral origin. 

Delirium. — Delirium is a common symptom ; it may occur early or 
late in the disease, may be violent or moderate, continuous or intermit- 
tent, not more frequently present in the fatal cases than in those which 
recover, and does not always correspond to an increase of temperature or 
to an aggravation of the other symptoms. 

Pain. — Pain, especially in the head, is a very common symptom, and 
is at times violent. It may be located either in the occipital or frontal 
regions, and may extend down the back. In some cases, especially in 
children, there are abdominal pains and also pains in the extremities. 
An almost constant symptom is hyperesthesia of the skin ; the patients 
do not like to be touched, and often the least jarring of the bed causes 
intense pain. According to Councilman, the general pain in the head is 
due to the inflammation of the meninges. The pain in the cervical 
region and back may be referred to pressure exerted on or inflammation 
of the posterior nerve-roots. 



SPECIFIC INFECTIOUS DISEASES. 437 

Coma. — There are great variations in the cerebral symptoms : there 
may be stupor, drowsiness, or deep coma, varying from day to day or 
from hour to hour ; insensibility may suddenly change to consciousness. 
Coma may occur in the beginning, and the comatose condition may con- 
tinue until death. 

Neck and Spine. — Symptoms connected with the neck are almost 
always present, and vary from a simple stiffness to rigidity of various 
degrees, w r ith or without retraction. Attempts to move the head are 
usually painful. The retraction of the neck is sometimes accompanied 
by opisthotonos, and all these symptoms can be referred to the effect of 
pressure on or inflammation of the spinal nerve-roots. 

Paralysis. — According to Bullard, these cases, while at times and in 
certain stages precisely resembling cases of paralysis occurring in anterior 
poliomyelitis, are to be distinguished clinically from the paralyses of this 
disease by the following conditions : 

1. In cases of paralysis following cerebro-spinal meningitis we find 
that pain on passive motion of the limbs persists to a degree rarely, if 
ever, found in anterior poliomyelitis. Such pain and tenderness sometimes 
exist during the acute stage of anterior poliomyelitis for two or three days, 
but if they last longer than a week the case is one in which the diag- 
nosis is to be very carefully considered. It is not uncommon, on the other 
hand, for great pain on passive motion of the limbs or of certain joints, 
especially of the ankles, to exist in cerebro-spinal meningitis for one, two, 
or more months after the acute stage of the disease has ceased. Tender- 
ness on pressure over the muscles also persists much longer than in an- 
terior poliomyelitis, where it rarely continues much beyond the acute 
stage, but does not last as long as the pain on motion, active or passive. 

2. The character of the paralysis also differs, at least in the early 
stages, although later it is often nearly indistinguishable. There is always 
a tendency to spastic contracture in the early stages of the paralysis of 
cerebro-spinal meningitis. This is sometimes so marked that it is evident 
on casual examination. Certain portions of the limbs are flexed, and 
there is a decided muscular resistance to passive motion due to a perma- 
nent tonic contraction. More often, and particularly in the later stages, 
this tonic or spastic condition is not so evident, and shows itself only or 
principally in the extreme degree of flexion at the ankle-joint, the foot 
often being in a position of equinus, and its axis almost in direct continu- 
ance with that of the leg. 

3. The knee-jerk is usually less affected than in anterior poliomye- 
litis. In other words, there seems to be a greater tendency to retain the 
knee-jerk. This is rather a question of degree than of anything else, and 
may have been accidental in Bullard' s patients ; he lays stress on it only 
in connection with other symptoms. The knee-jerk is sometimes in this 
affection, as in anterior poliomyelitis, totally abolished. 

4. In addition to these clinical signs we have the history of the initial 



438 PEDIATRICS. 

attack to guide us. While certain cases occur in which it is difficult to 
determine the character of the initial attack, as a rule, the existence of 
retraction of the head and of contractures of the muscles of the back or 
limbs, the continued presence of extreme tenderness or pain on movement, 
and the duration of the acute stage of the disease, enable us to determine 
more or less accurately the character of the disease. 

Any case is suspicious in which the acute stage lasts more than seven 
days. 

Lungs. — Although instances of pneumococcus pneumonia are quite 
often met with in connection with meningitis, and sometimes with diplo- 
coccus meningitis, yet it will probably be found in the future that the 
meningitis which accompanies pneumococcus pneumonia is a pneumo- 
coccus meningitis, while in the epidemic meningitis the complicating pneu- 
monia is caused by the diplococcus intracellularis. This view is especially 
upheld by Leichtenstern, who states that while epidemic meningitis is rare 
in many countries, occurs chiefly in early life, and has no crisis, pneu- 
monia is common all over the world, at all ages, and has a distinct crisis. 
The complications of the two diseases are different. Multiple synovitis 
and affections of the eye, so frequent in epidemic meningitis, are rare in 
pneumococcus meningitis. The exudation is more fibrinous in the latter 
disease, and the result usually rapidly fatal, while the epidemic form is 
frequently recovered from. The remissions and exacerbations, varying 
course, relapses, and uncertain gait belong exclusively to the epidemic 
form. Leichtenstern also believes that the cerebral symptoms dependent 
on a pneumococcus pneumonia subside at the time of the crisis, just as 
the other symptoms do. The diplococcus intracellularis can enter the 
lung and produce a focal pneumonia characterized by especial anatomical 
features, and occurring in both the acute and chronic cases. 

Skin. — The lesions of the skin gave, in the earlier epidemics, the name 
of spotted fever to the disease. These lesions vary greatly, and may be 
represented by petechias, larger hemorrhagic foci, or circumscribed areas 
of hyperemia ; the most common form of efflorescence is, however, herpes. 
In numbers of cases there are no lesions of the skin whatever. A taehe 
cerebrale is of common occurrence. 

Eye. — Symptoms connected with the eye are prominent in epidemics 
of meningitis, and there is a marked tendency for the infection to extend 
along the optic nerve, as already described in the pathology. The cause 
of the lesions (neuritis or degeneration of the nerves of the eye) may be 
due to their involvement in the exudation at the base of the brain without 
any extension of the inflammatory process to either the orbit or the eye. 
Or the optic nerves may also be involved in this exudation. Again, the 
inflammation from the meninges may extend directly from the brain 
into the eye by means of the piarachnoid. All of the cases of purulent 
choroido-iritis and the very rare cases of suppuration in the orbit are 
probably due to such extension. There is no metastasis in these con- 



SPECIFIC INFECTIOUS DISEASES. 439 

ditions, but a direct extension. A third cause of the lesions of the eye, and 
one to which most of the cases of keratitis are due, is a neuritis of the fifth 
nerve, with destruction of the Gasserian ganglion and a loss of sensation. 

The pupils are generally altered. Reaction to light is slow and in- 
complete, and dilatation is very apt to occur. Paralysis of the ocular 
muscles with resulting strabismus may develop, but the paralysis is 
often temporary, and different muscles may be affected at different times. 

Ear. — As in the eye, so in the ear, the infection may extend along the 
auditory nerve. There may be pain, tenderness of the mastoid, and deaf- 
ness with or without otitis media. The lesions in epidemic meningitis are 
always secondary and are due to extension from the brain, while when 
the meningitis is secondary to an otitis media the organism of infection is 
the pneumococcus or streptococcus. These lesions of the ear are the 
most common complications of epidemic meningitis, and in a large num- 
ber of cases deafness results. 

Nose and Throat. — Acute coryza and inflammation of the throat may 
occur. The lesions may be due to a primary extension from the brain or 
from a direct secondary infection from the ear. These questions, how- 
ever, have not yet been satisfactorily determined, and it is possible that 
the diplococcus intracellularis may be found in the nasal secretion of 
patients without meningitis. 

Joints. — Acute inflammation of the joints is frequent in epidemic 
meningitis. The knees are the joints most commonly affected. 

Pulse and Temperature. — A marked characteristic of epidemic cerebro- 
spinal meningitis is the inequality of the pulse and temperature. The 
pulse may often remain normal while the temperature is heightened, and 
there is no relation between the height of the temperature and the se- 
verity of the symptoms. The temperature rarely reaches 40° C. (104° 
F.), and varies from 39° C. (102.2° F.) to 38° C. (100.4° F.). The type 
is often remittent. The fever gradually disappears and the temperature 
curve is interrupted by irregular rises and falls. A terminal rise of tem- 
perature occurs in some cases. The pulse shows the same irregularity as 
the temperature, and may range from 70 to 130 in a minute. Relative 
slowness of the pulse to the temperature is often found in children. Ab- 
solute slowness of the pulse is not common. 

Blood. — Leucocytosis is usually present. The leucocytes gradually 
diminish towards the end of the disease in the cases which recover. Iodo- 
philia is generally marked. 

Spinal Fluid. — In cerebro-spinal meningitis the character of the fluid 
is more or less turbid, and in severe acute cases a puriform deposit fre- 
quently settles to the bottom of the test-tube in a short time ; there are 
numerous polymorphonuclear leucocytes (pus-corpuscles) and occasional 
smaller mononuclear lymphoid cells and fibrin. Groups of the diplococcus 
intracellularis are found in varying numbers in the protoplasm of some of 
the leucocytes. The fluid should be withdrawn at the time when the active 



440 PEDIATRICS. 

symptoms are present, or the growth of the organism may fail to be ob- 
tained. A microscopic examination is necessary in all cases, as the macro- 
scopic appearance of the fluid is not to be relied on. Inoculation experi- 
ments are, as a rule, unsuccessful, as the organism is not pathogenic for 
guinea-pigs. Goats are susceptible to it. 

Mental Condition after Recovery. — In some cases after recovery from 
the acute symptoms a condition of mental impairment remains. 

Diagnosis. — The differential diagnosis of cerebro-spinal meningitis is 
essentially from other forms of meningitis, whether tubercular or non- 
tubercular. The sudden onset, extreme headache, hyperesthesia, opis- 
thotonos, rigidity and retraction of the neck, pain and tenderness of the 
neck and spine, herpes, moderate temperature in comparison with the 
severity of the symptoms, and rapid development of apathy and coma in 
keeping with the early exudation of pus over the surface of the brain, are 
in strong contrast to the slow onset and gradual development of the symp- 
toms in tubercular meningitis, described on page 407. The non-tubercular 
forms of acute meningitis are more difficult to differentiate, and the only 
exact means of diagnosis is by lumbar puncture. Epidemic influenza at 
times simulates epidemic cerebro-spinal meningitis so closely that the dif- 
erential diagnosis can only be made by spinal puncture. 

Prognosis. — The prognosis, where the child is young and the onset is 
violent, with high temperature and continuous convulsions, is very serious y 
as the disease is one of the most fatal in childhood, and only about one-half 
recover (Sachs) ; but even in the apparently fatal cases, where coma has 
intervened, a change may take place and the child recover. The first two* 
weeks are usually the critical period, so far as the acute form of the dis- 
ease is concerned. According to Sachs, the cases in which the coma de- 
velops rapidly, and does not show any signs of receding within the first, 
week or two, are almost certain to end fatally. If the coma has been slow 
to develop, the process is usually less intense and the prognosis is better ; 
but even in these cases, if the coma remains stationary for a week or 
more the chances of recovery lessen every hour that the coma continues. 

The chronic form is apt to prove fatal, both from exhaustion and from 
the development of more serious central nervous lesions. 

The cases which recover are often left with permanent lesions, causing 
deafness, blindness, various paralyses, and mental impairment. Death is 
very apt to occur quietly. 

Treatment. — The treatment of cerebro-spinal meningitis varies accord- 
ing to the severity of the symptoms. In most cases sedatives, such as 
the bromides, are indicated, and where the pain is severe opium in con- 
siderable doses is often needed. The ice-bag or Letter's coil applied to 
the head, and absolute quiet in a darkened room, are important adjuvants 
to the treatment. In many cases the pulse becomes so weak and the 
prostration so marked that stimulants are required until convalescence is 
established, when they can usually be replaced by tonics. In some cases 



SPECIFIC INFECTIOUS DISEASES. 441 

the hyperesthesia and general sensitiveness to noise, light, and motion in 
the room are so extreme and so characteristic that the attendants should 
be cautioned not to touch the child or the bed unnecessarily, and absolute 
quiet should be enforced in the room and throughout the house. 

The following cases illustrate cerebro-spinal meningitis ; where, as in 
some instances, the diplococcus intracellularis is not mentioned, it is be- 
cause these cases occurred before lumbar puncture was commonly used 
for diagnosis. 

A boy, thirteen years old, had never had any special diseases, but had been 
rather delicate for a number of months. He went to a Christmas party on December 
25, and on returning from the party complained of the motion of the sleigh in which 
he rode home. On the following day, in the afternoon, he was found to be listless, 
to have his tongue coated but not dry, a temperature of 40.5° C. (105° F.), and a pulse 
of 140. He complained of tenderness and pain in the back of his neck ; there was 
also tenderness in the abdomen. He appeared to be somewhat dull. 

On the following day the temperature in the morning was 39.4° C. (103° F.), and 
the pulse was 120. He was much more dull and apathetic than on the previous day, 
and in the afternoon became delirious. In the evening he had involuntary passages 
of urine and loose discharges from the bowels. His temperature was 40° C. (104° F.). 

On the following day his temperature was 39.4° C. (103° F.), and the respirations 
varied from 40 to 80 and were regular. He was unconscious. Subsultus tendinum 
was present. There was retraction of the head. The pupils did not respond to light, 
but were equal in size. A tache certbrale was present. 

On the evening of the following day, four days from the onset of the disease, he 
died. 

The autopsy showed the convex surface of the entire brain and cord to be covered 
with a thick exudation of pus, the spleen to be enlarged, and the case to be one of 
acute cerebro-spinal meningitis. 

A child, two years old, was brought to the hospital with the history that it had 
been showing symptoms of malaise for six weeks. Two weeks previous to entering 
the hospital it had a convulsion, and the indefinite and general symptoms had become 
more pronounced. There had been loss of appetite, with constipation, at times- 
vomiting, slight cough, and a heightened temperature. 

The head was retracted, and the muscles of the neck were rigid. The eyes were 
staring, but the pupils reacted to light. There was, at times, slight opisthotonos. 
The abdomen was retracted. The emaciation was extreme, so that the vertebrae and 
ribs became quite prominent. The child was apparently unconscious, and did not 
notice objects which were brought before its eyes, although the eyes were open. It 
moaned at times, and occasionally the legs were drawn up. No efflorescence was de- 
tected anywhere on the skin. The temperature varied from 36.6° to 38° C. (98° to 
100.5° F.). Sometimes it cried out sharply, as though in pain. A tache cerebrale was 
often present. 

The treatment of this case was simply the frequent administration of milk, with 
the addition of stimulants when indicated by the weakness of the pulse. The child 
was in so apathetic a condition that the use of any drug was unnecessary. Although 
at times it cried out as if in severe pain, yet these attacks were not sufficiently long 
to necessitate their control by an opiate. 

During the following month the child remained in very much the same condition. 
The head was retracted at times, and the emaciation became extreme, the abdomen 
being very much sunken (boat-shaped). In the next two weeks the nourishment was 
taken more readily, the head was less retracted, and he began to notice objects around 



442 PEDIATRICS. 

him, but he vomited once or twice nearly every day. The temperature at this stage 
of the disease became normal. 

One month later, which was two months from the time when the child entered 
the hospital, he was able to sit up without help. There was no retraction of the 
head, but the muscles of the neck were very rigid, and the head showed a tendency 
to retraction. 

During the following month the child continued to improve slowly, increased in 
weight, recovered his appetite, and when seen one month later was found on physical 
examination to be in a normal condition. 

The following case of epidemic cerebro-spinal meningitis occurred in 
the service of Dr. Buckingham at the Children's Hospital. 

The child was two years and eleven months old. She was breast-fed for fifteen 
months. At eight months she had scarlet fever ; at eighteen months she contracted 
measles. With these exceptions she had always been well and strong. Two days 
before entrance to the hospital she fell and struck her head. She complained subse- 
quently of headache. The day before entrance she vomited several times, and held 
her hands to her right ear as if in pain. There was no history of disease of the ears, 
of retraction of the head, of rigidity of the neck, or of convulsions. 

The physical examination showed nothing abnormal aside from a considerable de- 
gree of rigidity of the posterior cervical muscles and pain when passive movements of 
the head were made. There was some hypertrophy of the tonsils, with coated tongue 
and some secretion in the naso-pharynx. The temperature was 38.8° C. (102° F.), the 
pulse 130, and the respirations 32. A specimen of urine could not be obtained. 

Two days later there was marked retraction of the head, with internal strabismus. 
The child was very irritable, and was evidently very tender on pressure over the back of 
the neck. On the day after entrance the ears were examined, and the auditory canals 
were found full of epithelial scales, which were removed, leaving the drum membrane 
and walls of the canal reddened. On the following day an acute serous effusion was 
noted in the middle ear. Paracentesis of the membrana tympani was performed and 
wicks inserted. 

On the third day lumbar puncture was performed. The cerebro-spinal fluid was 
cloudy, with slight formation of fibrin. The cells were chiefly polynuclear leucocytes, 
with some mononuclear cells. Occasional organisms were found within the cells. Cul- 
tures from the fluid showed the presence of the diplococcus intracellularis. There were 
several single colonies, as well as fine, diffuse, pin-point growths between, on the culture- 
medium. 

For six days the temperature gradually declined, and nearly reached the normal. 
The child sat up of its own accord, and freely moved its head. There was no strabis- 
mus. It then began to grow slowly worse. The temperature rose with considerable 
morning and evening variations, and for nearly a month ran a very irregular course, 
the evening temperature ranging between 39.4° C. (103° F.) and 40.4° C. (104.8° F.). 
The pulse varied from 120 to 146, and the respirations from 30 to 35. ' The aural symp- 
toms disappeared, but the child grew more irritable ; retraction, tenderness, rigidity, and 
strabismus all returned. There was cough and an associated bronchitis. There were no 
convulsions or coma. The child was quiet but easily aroused. There was no general 
hyperesthesia. The urine one month after entrance was examined and found normal. 
Loss of weight was very noticeable. Towards the end of the fourth week in the hos- 
pital the temperature began to fall, the symptoms gradually diminished, the mental and 
physical condition improved steadily, but there seemed to be a moderate degree of 
paralysis of the legs, which was slow in passing away. Convalescence was prolonged 
over a period of five weeks, when the patient was discharged to the convalescent home 
much relieved, but with the legs still not entirely under control. 



SPECIFIC INFECTIOUS DISEASES. 443 

The following case was that of a girl eight years old, who represented 
that form of cerebro-spinal meningitis which is designated chronic, and 
only a few cases of which have been reported. 

Her parents were said to have been healthy, and there was no evidence of tuber- 
culosis or syphilis in the family. A brother whom I saw in consultation died of cere- 
bro-spinal meningitis. With the exception of an attack of measles and of whoop- 
ing-cough, the child had not had any other diseases. She had not been entirely 
well since an attack of pertussis, which occurred one year previous to entering the 
hospital, and her attack of cerebro-spinal meningitis had begun four and a half 
months previously. 

The onset of the attack was sudden. She went to bed in fairly good condition, 
but woke up in the night delirious, screaming, and apparently not recognizing her 
parents. These symptoms continued until the following week. There were no convul- 
sions. A week later vomiting occurred every two or three days. This was not de- 
pendent upon food, and had occurred at intervals up to the time of entering the 
hospital. The bowels were constipated. There had been more or less opisthotonos 
from the beginning of the illness, and also in the beginning there was decided retrac- 
tion of the head. The stiffness of the neck had gradually diminished, but at times 
returned. Up to the time of entering the hospital the child was said to have had 
constantly a heightened temperature, varying from 37.7° to 39.4° C. (100° to 103° 
F.), with a rapid pulse and quick respirations. Nothing abnormal had been found in 
the urine. There had been no efflorescence on the skin. 

Fig. 108. 




Chronic intermittent cerebrospinal meningitis. Tache cerebrale showing on right thigh. Female, 

8 years old. 

Four weeks previous to entering the hospital the child was noticed to be blind. 
This had occurred suddenly. The child had had constant headache, and shortly after 
the beginning of the attack showed a loss of power of motion in both legs. At times 
there had been incontinence of faeces and of urine. An examination of the urine 
showed it to have a specific gravity of 1015, to be normal in color, to have an acid reac- 
tion, and not to contain albumin or sugar. No evidence of syphilis was detected. 
She sometimes showed improvement in her general symptoms and became conscious, 



444 



PEDIATRICS. 



Fig. 109. 




Secondary choroidoiritis occurring 
cerebro-spinal meningitis. 



but she was unable to sit up or to walk. As shown in Fig. 108, she was somewhat 
emaciated. 

There was extreme hyperesthesia of the body and extremities. The slightest mo- 
tion of the bed caused discomfort and pain. An examination of the thoracic and ab- 
dominal organs showed that they were normal. 
The pulse was 80 and regular, the respirations 
were natural, the temperature was 37.7° C. (100 a 
F.). She sometimes had an attack characterized 
by spasmodic contractions of all the muscles of the 
body, lasting for about thirty seconds. At these 
times there was no loss of consciousness, and the 
child screamed for some time afterwards as though 
in pain. During the attacks the pulse grew feeble 
and intermittent, the respirations slow and super- 
ficial, and the extremities cold. Brandy was given 
subcutaneously, and reaction took olace. There 
was a decided tache cerebrate. 
Fig. 109 shows the condition of her eyes. The pupils reacted, and the retinae were 
evidently sensitive to light, yet apparently she was blind. 

In the middle of the eye was a yellowish mass with an irregular border. There 
was a very slight hyperemia in the ciliary region. The iris seemed slightly pushed 
forward, and its pupillary edge was a little uneven. A yellowish or yellowish-white 
reflex appeared from the fundus of the eye even without the use of the ophthalmoscopic 
mirror, and it was not difficult to distinguish that this reflex did not come from the 
level of the lens, but that it was situated deeper. The tension of the eyeball was very 
much reduced, and there was very little tenderness on pressure. 

These yellowish appearances in the pupils are sometimes called pus emboli, and 
also metastatic choroido-iritis • but while in other forms of meningitis metastasis may 
occur, it does not occur in the epidemic form, but is a direct extension. 

In the other forms where it does occur, both the meningitis and the lesions of the 
eye are due to metastasis. Sometimes this yellowish mass fills the vitreous entirely, 
sometimes only in part. It may have blood-vessels on its surface. 

The child remained in about the same condition for some time. At times she- 
screamed as though in pain, but she took her nourishment fairly well. She had one 
slight convulsive attack, which involved mainly the upper extremities, the lower ex- 
tremities being only slightly contracted. During this attack her thumbs were turned 
in, her fingers clinched over them, and her arms, which were usually extended at her 
sides, were flexed at the elbows. Her face showed no sign of spasm, and during the 
attack the radial pulse was full, soft, and regular. After a few seconds the muscles- 
again became relaxed, and there was no further tendency to contraction. The usual 
position in which she lay during the following weeks was with the thighs slightly 
flexed and abducted, and the legs flexed at the knee, with the heels almost touching 
each other. About two weeks after entering the hospital the right leg became flexed. 
on the thigh to such an extent that the knee almost touched the chin and the heel 
rested on the vulva. Any attempt to extend the leg made the child cry out as though 
in pain, the left leg being naturally extended in bed. This condition of the right leg- 
continued for several days and then disappeared. Some days later a slight convulsive 
attack took place, which seemed to affect the right side more than the left. 

The temperature during the eighteen days when the child was in the hospital 
varied from 37° to 38.8° C. (98° to 102° F.). The pulse during this time varied: 
from 68 to 100 ; the respirations sometimes varied from 34 to 52, but were usually 
about 28. 

The fingers were flexed most of the time, and there was so much rigidity of the 




SPECIFIC INFECTION DISEASES. 445 

limbs that the reflexes could not be satisfactorily determined. Later in the disease 
there was slight cyanosis of the cheeks and lips, and an eruption of milia on the 
chest apparently arising from her continually perspiring day and night. She lay in a 
stupor all the time, except when she was moved, when she would cry out. She showed 
no signs of understanding anything that was said to her. Sometimes she would be 
seized with an attack of rapid breathing lasting several hours. The bowels had been 
constipated at first, but later diarrhoea occurred. There was incontinence of faeces and 
urine, but no vomiting. The teeth were kept closed, and had to be forced apart when 
she was fed. Once she had a convulsion, in which the 
head was drawn back, the body and extremities were Fig. 110. 

rigid, and the eyes rolled up. 

Eighteen days after entering the hospital the child was 
taken to her home, so that the daily record could not be 
obtained. 

An examination made two weeks after she left the 
hospital showed a spastic condition of the extremities and 
neck. 

When seen by Dr. Bullard at this time the child took 
no notice of her surroundings, and her eyes when opened 
had a vacant expression, due largely to the mental condi- 
tion, although she was undoubtedly blind. The extremi- 
ties were much wasted, and were all in a condition of 
spastic rigidity. There was slight flexion of the thighs on 

the body and of the legs on the^thiffhs, while the feet were . Chronic cerebrospinal men- 

J e ingitis. Spastic condition ot 

extended in nearly a straight line with the legs. hand five and a half mon ths 

The hand, as shown in Fig. 110. was tlexed almost at after onset of the disease, 
right angles to the wrist. The proximal phalanges of the 

fingers were hyperextended, while the other phalanges were flexed. The thumb was 
strongly adducted, and its distal phalanx was flexed. 

This is a position of the hand frequently found in the later stages of spastic paral- 
ysis, and is due to the preponderant contraction of the flexors of the wrist and weak- 
ness of the interossei and lumbricales. 

The child gradually grew weaker, and died of exhaustion a few weeks later. 

These chronic cases are rare. In two other cases which came under my observa- 
tion the children eventually died from a prolonged sickness of many months, during 
which they at times seemed to be recovering. Cases have been reported by others, as 
by Henoch, of Berlin, to have recovered. 

The following case was seen in consultation with Dr. Townsend : 

A boy, four and a half years old, had been previously well, with the exception of 
an attack of measles when he was one year old. 

On May 9 he was suddenly attacked with vomiting, which continued at intervals 
for two days. From the beginning of the attack he complained of severe pain in the 
head and abdomen. On the second day of the attack there was much contraction of 
the head, and he was slightly delirious, although rational most of the time. The 
temperature was raised from the beginning of the attack. There were no convulsions. 
The bowels were not moved during the first week of the disease. When first seen by 
Dr. Townsend the pulse was 124 and regular, the temperature 38.8° C. (102° F.), and 
the respirations 20 and regular. There was slight opisthotonos. There were no con- 
tractions of the muscles of the limbs. The symptom of Kernig was present. There 
was no tenderness along the spine. The cutaneous sensibility was everywhere 
normal. There were no cutaneous efflorescences or ecchymoses. The pupils were 



446 



PEDIATRICS. 





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regular and reacted normally to light. There was no 
strabismus or photophobia. Nothing abnormal was de- 
tected on physical examination. The child was appar- 
ently in great pain, cried out a great deal, and moaned 
continually. The suffering during the next few days 
was so great that morphine in doses of 0.002 gramme 
(aV grain) had to be given. This dose had to be in- 
creased so frequently that it was found that the child 
took 0.015 gramme {\ grain) before relief was obtained. 
Applications of ice to the head and spine gave no relief, 
and for a number of days it was found that there was 
needed to control the restlessness and pain 0.01 to 0.02 
gramme (£ to | grain) of morphine during the twenty- 
four hours. 

On the twenty -fourth day of the disease the temper- 
ature, which had varied from 37.7° to 39.4° C. (100° to 
103° F.), became normal, remaining so until the forty- 
seventh day. During this time the head was only 
slightly retracted, and the child seemed free from pain, 
but remained in a very listless condition, not speaking, 
and taking but little nourishment or stimulants. He be- 
came emaciated, passed his urine and faeces involuntarily, 
and occasionally vomited. Nutritive enemata were not 
retained, but on the forty-first day of the disease pepto- 
nized milk was retained, and on the forty-sixth day he 
was able to take gruel, and at that times talked and 
laughed. 

On the forty-seventh day of the disease a relapse 
occurred, the temperature rising to 39.7 C. (103.6 F.). 
The head was rigidly drawn back, the eyes were staring, 
and the pain returned. The symptom of Kernig, which 
had never disappeared entirely, again became well 
marked. At this time I saw the child with Dr. Town- 
send. On the sixty-sixth day of the disease the con- 
vulsive movements of the left arm and leg, with turning 
in of the left eye, occurred. Several days previous to 
this relapse a number of sudamina appeared on the 
neck and trunk, and an evanescent erythematous erup- 
tion on the neck and face, lasting only a few hours. 
From the sixty-first to the sixty-sixth day of the disease 
his body was covered with a macular efflorescence, the 
macules varying in size. Ecchymoses were at no time 
seen, and repeated examinations of the chest and abdo- 
men showed nothing abnormal. 

From the seventy-first day to the seventy-third day 
the temperature was again normal, the child took his 
food well, the neck was straight, and his general appear- 
ance was encouraging. 

On the seventy-fourth day he again had convulsive 
movements, most marked on the left side of the body. 
The head was drawn back, and at noon the next day his 
temperature was 39.4° C. (103° F.). The pulse, which 
during the entire illness ranged from 120 to 140 and 



SPECIFIC INFECTIOUS DISEASES. 447 

had previously been regular, was now at times irregular and intermittent. The bowels 
were constipated at this time. 

After this, although the temperature became normal, the child failed rapidly, and 
there was so much emaciation that the finger and thumb could easily encircle his thigh. 

He died quietly on the eighty-seventh day from the time of the onset of the disease. 

It was very difficult, indeed impossible, to give a prognosis in this case, as at 
times it seemed as though he would recover, and then the temperature would rise 
again and the unfavorable symptoms would return. 

The chart shows the temperature from the tenth day of the disease. 

TYPHOID FEVER. 

Typhoid fever (enteric fever, typhoidal ileo-colitis) is an infectious dis- 
ease produced by the bacillus of Eberth. The conditions and manifesta- 
tions of typhoid fever as it appears in the foetus, in the young child, and 
in the adult differ markedly. 

Typhoid in the Foetus. — The infection of the foetus may take place 
from the mother. Abortion occurs in from fifty to seventy per cent. It 
is now well established that the bacillus of typhoid can pass through the 
placenta from the mother to the foetus, and it seems probable that this 
can happen when the placenta is intact. In most cases the foetus dies in 
utero ; it may, however, be born alive but suffering from the infection. 
Again, the foetus may be born alive and healthy, after having passed 
through the infection in utero. Finally, it may not be infected at all, 
although the mother may have had the disease. When at birth the foetus 
is infected it rapidly succumbs, the infection showing itself in the form of 
acute cachexia without any special characteristics. The bacilli in these 
cases are most commonly found in the liver, spleen, and blood ; they may 
also be found in the intestine. Marked lesions in the intestine and mes- 
enteric glands are, however, never found, the organs usually being nor- 
mal. The liver and -spleen are sometimes swollen, and may show minute 
hemorrhages. An explanation of these lesions is found in the entrance 
of the bacillus through the umbilical veins, — that is, the septicaemia is 
primary and not secondary to an enteritis. These cases correspond to 
those of typhoid fever in adults in which there are no intestinal lesions. 
There may also be an infection with other organisms besides the typhoid 
bacillus, especially the staphylococcus aureus. 

Typhoid in Infancy and Early Childhood. — The pronounced patho- 
logical lesions, severe symptoms, and great virulence in type which are 
so characteristic of typhoid fever of later years are so rare in infancy and 
early life that the following description will be confined to the latter 
period. 

Etiology. — Typhoid fever is exceedingly rare in the first two years of 
life, is uncommon under three years, and after the fifth year becomes 
more common as the child grows older. Under two years the number 
of cases reported, even if correct, is small. In fifty-five cases collated in 
1895 by Stowell, the diagnosis in twenty-eight seemed probable ; in the 



448 PEDIATRICS. 

others it was doubtful, as no bacteriological examination was made. The 
youngest authentic case of typhoid contracted after birth is that reported 
by Gerhardt in an infant which presented the symptoms when twenty- 
five days old, and recovered in twelve days. In Stowell's series sixteen 
confirmative cases have been reported. Eight of these cases died. In- 
fection may take place in any way by which the germs of the disease can 
be carried from one individual to another. The germs are given off 
from the discharges, chiefly the faeces and the urine. The individual is 
infected largely through the gastro-enteric tract, and the most usual mode 
of conveyance into the body is by infected milk or water. Direct trans- 
mission by the hands which have been infected from the surroundings of 
the patient, especially from the clothes and bedlinen, is possible. 

Pathology. — After birth in the earlier periods of life the pathological 
lesions are less definite in direct ratio to the age. After the second or 
third years the lesions are constant and the pathology definite. Although 
the more advanced and severe lesions of typhoid fever may occur in the 
early as well as in the later years of life, yet its characteristic lesions in 
young subjects are found in the milder and less severe pathological 
changes of the disease. These consist essentially of a hyperplasia of the 
solitary lymph-follicles and Peyer's patches, and the process, instead of 
going on to ulceration, usually terminates in early resolution with fatty 
degeneration of the cells. Hemorrhage and perforation are therefore rare 
complications in the typhoid fever of early life. There is, however, 
nothing distinctive of typhoid fever in this hyperplasia of the lymph- 
follicles in children, for it is not uncommon to find this condition when 
death has occurred from other diseases of the intestine. It may also be 
present in such diseases as measles, diphtheria, and scarlet fever. Very 
marked hyperplasia of the lymph-follicles may be produced in children 
by irritating substances and by foreign bodies, not only food, but also 
drugs, such as turpeth mineral. I have, in fact, seen, at the post-mortem 
examination of a child, marked enlargement of the lymph-follicles caused 
by doses of turpeth mineral given during life as an emetic. 

In addition to the lesions in the intestine, hyperplasia of the mesen- 
teric glands, granular degeneration of the liver and kidney, and granular 
or fatty degeneration of the heart may be found. Parenchymatous 
changes sometimes occur in the peripheral nerves and degeneration of 
the muscles. The pathological conditions in typhoid fever in the early 
years of life may be said to correspond with those which are met with 
in the aborted forms of the disease in later life. 

The specific efflorescence of typhoid fever, the rose-spots, have ac- 
quired additional importance in the diagnosis from the recent bacterio- 
logical investigations by Neufeld and Curschman in Germany, and Rich- 
ardson in this country. These observers have demonstrated the presence 
of the typhoid bacillus in the rose-spots in a very large proportion of the 
cases examined. In Richardson's series the diagnosis was made by this 



SPECIFIC INFECTIOUS DISEASES. 449 

method on an average of six days before the appearance of the Widal 
reaction. 

Incubation. — The stage of incubation in typhoid fever may last from 
one to two weeks ; a shorter time, however, five days, and a longer one, 
three weeks, have been observed. 

Symptoms. — The prodromal stage is usually short, young subjects 
having less power of resistance to the poison than adults, in whom the 
prodromal stage is often prolonged. The onset is more likely to be acute 
in young children, and nervous symptoms, especially vomiting, are com- 
mon. 

The duration of the disease is generally much shorter than in adults. 
This short duration depends largely upon the mild form of the intestinal 
lesions and usually indicates that marked ulceration has not taken place. 
As shown by the figures collected by Morse, the average duration of 
typhoid fever in children is a little less than three weeks, the younger the 
child the shorter the duration, and the proportion of cases in which the 
duration is ten days or less is twice as great in the younger children. 

As a rule, the temperature is moderate, but it may be high, as in 
adults, without, however, producing as severe symptoms, since children are 
generally less affected than adults by a high temperature. When the 
lesions are mild the temperature is not apt to show so typical a course as 
when they are pronounced. The temperature often rises rapidly in the 
beginning, and although it returns to the normal by lysis, it does not 
show so gradual a lysis as when marked lesions have occurred, and when 
other symptoms of toxaemia have complicated the disease. The younger 
the child the lower the range of the temperature and the sooner is the 
maximum reached. The remittent stage occurring in adults is much less 
in children and the defervescence is rapid. 

The pulse is usually accelerated, but is low in comparison with the 
height of the temperature in other diseases, and is not so apt to vary from 
the normal in strength and rapidity. Haemic murmurs are not uncommon. 

The respirations are not especially increased unless some complica- 
tion is present. Although bronchial catarrh may in most cases be patho- 
logically present (Morse), yet clinically its importance in children has been 
rather over-estimated. In certain cases in young children, however, it is 
so marked as to be liable to lead to the error of considering the primary 
cause of pulmonary origin rather than intestinal. 

The abdomen may be distended and tympanitic, but this symptom is 
often not marked. In Morse's statistics distention occurred in from 50 to 
70 per cent, of all cases. It is more common in older children, and not 
infrequently is extreme. Pain and tenderness of the abdomen are rather 
unusual. Vomiting, especially at the onset of the disease, is often met 
with, but is rare in the later stages of the disease. Constipation, especi- 
ally in young children is more common than diarrhoea. The discharges 
are not so characteristic as in adults, and when diarrhoea is present, the 

29 



450 PEDIATRICS. 

stools, as a rule, are not so frequent or so large in amount. All the fatal 
cases noted by Morse had diarrhoea. Intestinal hemorrhage is very 
unusual under ten years of age, and is fatal in about half the cases. 
Perforation is exceedingly rare. Although it is probable that in all cases 
of typhoid fever there is some enlargement of the spleen, it is often im- 
possible to detect this change by palpation, and percussion of the spleen 
in young children is well known to be very misleading. According to 
Morse's figures the spleen is demonstrably enlarged in 90 per cent, of all 
cases of typhoid in children, and the older the child the greater the 
enlargement. The return of the spleen to its normal size indicates con- 
valescence and recovery, while persistent enlargement shows that the dis- 
ease is still present. 

Epistaxis occurs more rarely than in adults. 

The rose-colored spots appear to be less frequently found in children 
than in adults. Morse's series of cases showed the spots in from 60 to 
70 per cent, of all cases in children. They usually appear in the second 
week. They consist of small, light-pink maculae, usually scattered, chiefly 
or solely on the abdomen, and disappearing under gentle pressure of the 
finger. Other varieties of efflorescences are seen at times, but are un- 
common. Herpes labialis occurs in some cases. 

The tongue is not so likely to be dry as in older subjects, and although 
coated it soon becomes clean at the tip and edges. There is at times a 
slight albuminuria at the height of the fever, but a complicating nephritis 
is rare. The diazo-reaction is usually present in the urine after the first 
week. The Wiclal reaction can generally be obtained in the second week. 

The more severe nervous symptoms so pronounced in later life are 
not prominent in early childhood. Headache of a mild type is common ; 
severe headache is very uncommon. Crying out at night, especially in 
young children, and delirium of a mild type are not uncommon. Deep 
stupor is rare ; in fact, the characteristic of typhoid fever in young chil- 
dren, as I have seen it, is apathy. The child takes the nourishment which 
is given to it, is not especially restless, and usually lies in a half-somno- 
lent condition. As the disease progresses it gradually returns to a more 
natural mental condition. Convulsions are rare. In some cases cerebral 
symptoms, simulating somewhat those of meningitis, arise, and are 
frequently due to cerebral congestion or to toxic action. These symptoms 
are more common in younger children. Hyperaesthesia, changes in the 
pupils, retraction of the head, and opisthotonos may be present, closely 
simulating meningitis. True meningitis caused by the bacillus of typhoid 
is rare, but can occur. A case of this kind with the bibliography has 
been reported by Wentworth in a girl four years of age, in the Transac- 
tions of the American Pediatric Society of 1899. Lumbar puncture in 
this case showed an enormous number of typhoid bacilli, but no other 
organisms were found. The higher the temperature the more pronounced 
are the nervous symptoms. 



SPECIFIC INFECTIOUS DISEASES. 451 

In typhoid the leucocytes are usually diminished in number, but 
there is a proportionate increase in the lymphocytes. In the early stages 
the erythrocytes are increased, as is also the haemoglobin. In the later 
stages a condition of secondary anaemia may occur, producing a diminu- 
tion of the red blood-corpuscles and haemoglobin. 

Complications and Sequels. — Pulmonary complications, with the ex- 
ception of bronchitis, are rare. Neuritis is not an uncommon complica- 
tion. Aphasia occurs rather more frequently in children than in adults. 
In rare cases it may be due to some organic cause, such as embolism, 
but, as a rule, there is no demonstrable lesion. According to Morse's 
statistics, in most cases it occurs where the typhoid had been extreme, 
accompanied by other marked nervous manifestations, and coming on 
during convalescence while the temperature was falling. The intelligence 
is retained, and there is rarely any other paralysis. Recovery was the 
rule, and the average duration was three weeks. Even when partial 
paralysis has accompanied the aphasia, entire recovery may take place. 
Chorea and parotitis are not very uncommon, and otitis media is not in- 
frequent. Relapses are about as frequent as in adults. According to 
Morse's figures, the number of days of fever in thirty relapses was fifteen, 
the shortest seven days, and the longest twenty-nine days. His number 
of days of apyrexia before the relapse varied from none to nineteen days. 
They follow about the same course as the normal attack, but, as a rule, 
are of shorter duration, the symptoms being less severe. 

Diagnosis. — Widal Reaction. — During the first few days typhoid fever 
may often be mistaken for various forms of febrile gastro-enteric disease. 
The most important means of diagnosis is by the Widal serum-reaction. 
Ry this is meant the clumping and loss of motility of the typhoid bacilli 
when the serum of a patient sick with typhoid fever is added to a bouillon 
culture of typhoid bacilli. A freshly prepared bouillon culture not more 
than twenty-four hours old and grown at room temperature should be 
used. Not less than ten parts of the culture should be added to one of 
the serum. No reaction occurring after half an hour should be accepted. 
This reaction is usually not present until the beginning of the second 
week, but may last for weeks or months after *the recovery. If, there- 
fore, a reaction is positive, it is necessary, in order to be accurate, to 
exclude a recent typhoid. While this is the most important method of 
diagnosis in typhoid fever, it is not absolute, as the reaction is not always 
present in typhoid, and may rarely occur in other diseases. The error is 
about five per cent, in either direction. 

Infants born alive or dead of mothers who have typhoid may or 
may not show the serum-reaction. The reaction may be transmitted to 
a healthy infant from the breast-milk. The reaction is less intense in 
the mother's milk than in her blood, and less in the infant's blood than 
in the milk. The agglutinating principle may not be transmitted to the 
infant through the milk. The transmission probably depends largely on 



452 PEDIATRICS. 

the strength of the agglutinating power in the blood and milk. The re- 
action disappears in a few days after the cessation of nursing. 

Diazo- Reaction. — Not so much value as formerly is attributed to the 
diazo-reaction, because it is also found in acute tuberculosis, septicaemia, 
measles, pneumonia, and probably also in many of the acute febrile 
diseases. It does not develop, however, in acute tuberculosis until after 
the third week of the disease ; whereas in typhoid, if it is to appear at 
all, it is usually obtained by the end of the first or in the second week. 

White Blood Count. — Another important aid in the differential diag- 
nosis of typhoid may be obtained by the white blood count. The absence 
of leucocytosis is the characteristic point of the blood in typhoid, and serves 
to exclude many other diseases in which leucocytosis is present. It is 
always to be borne in mind, however, that a high white blood count may 
be found in a case of typhoid which is complicated by some disease 
which is accompanied by a leucocytosis. Typhoid fever, therefore, is not 
to be excluded because of a leucocytosis, unless complicating conditions 
can positively be proved to be absent. 

Typhoid Bacilli in the Rose-Spots. — The detection of the typhoid bacilli 
in the rose-spots is a point in the differential diagnosis which may be 
attempted in all doubtful cases ; their presence makes the diagnosis 
certain. In making the differential diagnosis, therefore, on a doubtful 
case of typhoid, the most important evidence is to be found in the results 
of the Widal and diazo-reactions, the white blood count, and the rose- 
spots. The onset of the disease, the course of the temperature, and 
the whole series of abdominal symptoms must be considered as supple- 
mentary and confirmatory evidence. 

The diseases which are most likely to simulate typhoid fever and 
render the diagnosis difficult are as follows : 

The Exanthemata and Pneumonia. — A number of acute diseases, such 
as the exanthemata and pneumonia may simulate in their prodromal 
stage those cases of typhoid fever which begin with violent symptoms. In 
pneumonia and scarlet fever there is leucocytosis, in typhoid fever there 
is none ; moreover, in the former diseases there is no Widal reaction and 
no diazo in scarlet fever. In measles, however, there is no leucocytosis, 
while the diazo-reaction may be present. After the prodromal symptoms 
have passed, the distinctive efflorescences of measles and scarlet fever and 
the course of the disease will serve to differentiate them, while the tem- 
perature curve and physical signs will determine the presence of pneumonia. 

Acute Ileo-Colitis. — Typhoid fever and ileo-colitis may sometimes simu- 
late each other. The intestinal symptoms of typhoid fever in young chil- 
dren, however, correspond so closely to the severity of the local lesions 
that it is rare in the early days of the disease to meet with the severe 
intestinal symptoms so common in ileo-colitis : those of typhoid, as a rule, 
being much milder. Later in the disease the splenic enlargement, efflores- 
cence, and tympanites of typhoid are not found in ileo-colitis. The blood 



SPECIFIC INFECTIOUS DISEASES. 453 

of typhoid does not show leucocytosis, while this is usually present in other 
forms of gastro-enteric infection. While the Widal and diazo-reactions 
are generally present in typhoid, the former never occurs, and the latter 
rarely, in gastro-enteric disease. The temperature curve also, after the 
early days of the disease, is of considerable aid in diagnosis. 

Tubercular and Epidemic Cerebro- Spinal Meningitis. — The vomiting 
which occurs in the prodromal stage of typhoid fever may, in connection 
with the child's apathy, simulate the early stages of tubercular meningitis, 
but the higher temperature, enlarged spleen, and distended abdomen of 
typhoid, and the absence of the irregular respirations, slow, intermittent 
pulse, and retracted abdomen of meningitis serve to differentiate the two 
diseases. In tubercular meningitis the evidence given by lumbar punc- 
ture and the absence of the Widal reaction separate the disease from 
typhoid. In both diseases the diazo-reaction may be present, and leucocy- 
tosis is absent in both. In rare cases the bacilli of typhoid, as already 
stated, may be the cause of a meningitis and the disease be diagnosticated 
during life by lumbar puncture. In cerebro-spinal meningitis the diplo- 
coccus intracellularis, obtained by lumbar puncture, is not found in 
typhoid ; there is marked leucocytosis, and while the Widal reaction is 
always absent, the diazo may be present. 

Acute Miliary Tuberculosis. — The most difficult of all the diseases to 
differentiate from typhoid is acute miliary tuberculosis. The absence of 
leucocytosis and the possible presence of the diazo-reaction occurs in 
both diseases, but the Widal reaction is not present in tuberculosis, and 
thus becomes invaluable in diagnosis. Until other evidence of tubercular 
processes appear locally, as in the lungs, it is often only by the persist- 
ence of the fever and prostration beyond the usual period of typhoid that 
tuberculosis can be distinguished from the prostration and continued fever 
of typhoid. It is especially in the typhoidal type of acute miliary tuber- 
culosis that the resemblance of the two diseases is closest, and when in 
typhoid the rose-colored spots do not appear and the Widal reaction is 
negative, the delirium, distended abdomen, enlarged spleen, and even 
the irregular temperature at times common to both diseases, may make 
the resemblance so close that the diagnosis cannot be made until the 
post-mortem examination. 

Malaria. — The differential diagnosis between typhoid fever and mala- 
ria is, at times, especially in children under two years of age, very diffi- 
cult and perhaps impossible until the blood has been examined. The 
difference in the temperature curve, the presence of the plasmodium, the 
marked effect on the symptoms by the use of quinine, and the absence 
of the Widal and diazo-reactions in malaria, are of much value in the diag- 
nosis from typhoid. Leucocytosis is absent in both malaria and typhoid. 

Epidemic Influenza. — Epidemic influenza may in its onset simulate 
typhoid fever, but the period of doubt is very short. The presence of 
Pfeiffer's bacillus, if it can be found in the sputum or nasal discharge, is 



454 PEDIATRICS. 

of importance, but the absence of the Widal and diazo-reactions are not 
of so much importance, as the disease has either run its course or de- 
clared itself by its temperature and irregular groups of symptoms before 
the time for obtaining these reactions has arrived. It is, therefore, impos- 
sible in the early days of the disease to make a positive diagnosis, and in 
some cases we are left in doubt as to the diagnosis at even a later period, 
when the symptoms of enlarged spleen, rose-colored" spots, and tympanitic 
abdomen of typhoid are not present as a group. The white blood count 
is of little service, as it is generally normal in epidemic influenza. 

Prognosis. — The prognosis of typhoid fever in early childhood is good. 
Statistics show that the disease is much less fatal in children than in adults, 
and that the mortality increases directly with the age. The complications, 
whether arising from local disturbance of the intestine or from cardiac and 
pulmonary disease, are rare in comparison with those met with in later 
life. The disease, however, varies very much in its severity in different 
epidemics and in different stages, and a child may have a severe type of 
typhoid fever and die from it. 

Treatment. — The treatment of the mild form and that most commonly 
met with in young children is exceedingly simple. The child should be 
kept perfectly quiet in bed as long as the temperature is raised, and for 
three or four days after it has become normal. Although in adults quite 
a varied diet can be given, in young children milk in some form through- 
out the whole course of the disease is indicated. There are no drugs 
which will either abort or. cure the disease. In the cases which begin 
acutely with vomiting, food should be withheld for some hours, and the 
prodromal symptoms treated' symptomatically, as the same symptoms 
would be in the beginning of a number of acute febrile diseases. After 
the acute symptoms have passed, alkaline milk should be given with 
low percentages of fat, sugar, and proteids at first, and these elements 
should be gradually increased in their percentages, and varied in their com- 
binations to suit the especial age and digestion. It is usually better to 
heat the milk to 68.3° C. (155° F.) and to add lime-water, five per cent. 
Where the stomach is at all irritable it is often well to peptonize the milk 
for a time. It is seldom that the temperature is so high as to call for any- 
thing beyond bathing, and, as a rule, antipyretics should be avoided. As 
a hygienic measure the child should be bathed twice daily with water 
heated to 32° C. (90° F.). If the temperature rises to 39.4° or 40° C. 
(103° or 104° F.) a reduction by artificial means is not necessarily indi- 
cated, but we should be guided by the general condition of the child. 
According to our experience at the Children's Hospital, a large number 
of children of all ages pass through an attack of typhoid without any 
necessity arising for the reduction of the temperature by baths or sponging. 
The older the child the more likely is the bath to be indicated. Much 
pulmonary or cardiac weakness contra-indicates the bath. The child can 
be either sponged for five or ten minutes, or wrapped in a thin blanket 



SPECIFIC INFECTIOUS DISEASES. 455 

and placed in the bath, while the body and limbs are actively rubbed. 
Where there is delirium and great restlessness, with a temperature of 
40.5° or 41.1° C. (105° or 106° F.) baths should be given every three or 
four hours, but with caution, as children do not react so well as adults. 
A stimulant, such as a few drops of brandy, should be given at the time 
of the sponging or bath. 

Technique of the Bath in Typhoid Fever. — A very convenient method 
of administering the bath in typhoid fever, or in any other condition in 
which the treatment is indicated, is as follows : 

A large rubber sheet is placed under the child on the bed, and the 
sides and ends are bolstered up by rollers or bedding, making, if properly 
arranged, a shallow but sufficiently large tub without the inconvenience 
of moving the child. A towel or blanket may be placed under the child 
if it is made uncomfortable by lying directly on the rubber sheet. The 
water is brought in a foot-tub to the side of the bed, and its temperature 
regulated according to the indications. A wet towel or sponge is placed 
on the head ; the water is then squeezed from a sponge on to the naked 
body with one hand, and brisk friction is applied with the other. The 
chest, abdomen, arms, and legs should be taken in rapid succession. It is 
especially to be noted that it is the combination of friction with water 
which accomplishes the best result in reducing the temperature and at 
the same time stimulating the peripheral circulation. The child is then 
turned on its side, and the back is bathed and rubbed in the same 
manner. The duration of the bath should vary from five to fifteen min- 
utes, according to the height of the temperature and the manner in which 
the child reacts. The temperature of the water should vary from 37.7° 
C. (100° F.) to 23.8° C. (75° F.), according to the age of the child, the 
height of the fever, the number of degrees of reduction in the tempera- 
ture obtained, and the manner in which the child reacts. A drop in the 
temperature of one to one and a half degrees centigrade is the object 
especially to be attained. The temperature is best taken one-half hour 
after the bath. Drops of two and three degrees centigrade are not de- 
sirable. If the bath is well given by an experienced nurse, a good reaction 
should usually be obtained. Slight blueness of the lips and finger-nails, 
cold hands and feet, and chilly sensations should be watched for and treated 
by a dose of brandy and water, an extra blanket, and heaters in the bed. 
Massage of the extremities under the blankets may be all that is necessary. 

Care of the Mouth and Skin. — The mouth should be gently but thor- 
oughly cleansed with a two per cent, solution of boracic acid in distilled 
water at least three times daily. The greatest care should be taken to 
prevent irritation of the skin by bathing the recumbent parts with alcohol 
and water. 

Diarrhoea, unless profuse and exhausting or very frequent, such as 
more than three or four in twenty-four hours, should not be checked. 
To control peristalsis bismuth and small doses of opium are indicated. 



456 PEDIATRICS. 

Constipation. — There is usually more difficulty with constipation than 
with diarrhoea. Enemata and suppositories are indicated rather than laxa- 
tives, which should be only used in extreme cases, and necessarily sparingly 
and in a mild form, such as the milk of magnesia 3.75 to 6.50 c.c. (1 to 
2 drachms), with an occasional small dose of castor oil. The discharges 
should be disinfected at once with a 1 to 20 solution of carbolic acid. 
All the clothing should be soaked in carbolic acid, twenty per cent., for 
six hours, and then boiled for one hour. 

Headache, Restlessness, Sleeplessness. — These nervous symptoms are 
best treated by bathing. If a sedative is desired, 0.12 to 0.3 gramme 
(2 to 5 grains) doses of trional are safe and efficient. Bromide of soda 
may be given alone or in combination with trional. 

Tympanites should be treated with hot cloths applied to the abdomen, 
or by turpentine stupes made in the following manner : one part of 
spirits of turpentine is mixed with six parts of sweet oil, and the mixture 
is then rubbed gently but thoroughly on the abdomen. A thick piece of 
flannel is then dipped in hot water, wrung out, and when sufficiently 
cool applied to the abdomen, covered with oiled paper, and kept in 
place by a thick swathe. If these precautions are taken, irritation of the 
skin will rarely be caused, and the treatment is very efficacious. Gentle 
irrigation of the colon with some saline solution, such as a two per cent, 
borate of soda or a three per cent, boracic acid solution, may be tried. In 
extreme cases the rectal tube may be used with caution. 

Hemorrhages and perforations should be treated as in the older cases, 
the former with absolute rest, with hypodermic injections of ergo tin 0.06 
c.c. (1 grain), and sometimes of morphine and cold to the abdomen, and 
the latter with hypodermic injections of morphine 0.001 to 0.003 c.c. (-g-V 
to 2-V grain). 

Laparotomy for perforation in typhoid has not been attended by bril- 
liant results, but in certain cases may be deemed advisable. The same 
care should be exercised during the convalescence of the child as in the 
advanced convalescence of the adult. 

Stimulants are not called for, as a rule, in the early stages of the dis- 
ease. When used they are best administered in the form, of brandy or 
whiskey. They are contra-indicated in the stage of toxaemia represented 
by marked excitement, active delirium, cerebral congestion with delusions 
and great restlessness, and a strong, full pulse. On the other hand, when 
the pulse is small and weak, when the mental condition is expressed by 
depression, low muttering, delirium, and a general condition of nervous 
exhaustion, the use of stimulants, especially in the form of alcohol, is dis- 
tinctly indicated, and is highly beneficial. For an infant of one year the 
amount of brandy or whiskey in twenty-four hours should vary from 15 
c.c. (J ounce) to 30 c.c. (1 ounce), but should never exceed 60 c.c. (2 
ounces). In children of four years these doses may be doubled in corre- 
sponding conditions. In all cases the stimulant should be well diluted. 



SPECIFIC INFECTIOUS DISEASES. 457 

If in a hemorrhage from the bowels a stimulant must be given, it should 
be administered in small doses and in combination with opium. A table 
giving the doses of other cardiac stimulants will be found on page 470. 
The following case, Fig. Ill, was under my care at the City Hospital : 

A boy, five years old, was taken sick with general malaise and fever five days 
before entering the hospital. There had been no other symptoms, such as epistaxis or 
vomiting. On entering the hospital, an examination showed the tongue to have a 
thick brownish coat in the centre and a thin coat on the tip and edges. The child was 
in an apathetic condition. The pulse was rapid and regular. Nothing abnormal was 
found in the thorax. The abdomen was distended and tympanitic, and showed one 
rose-colored spot. The spleen could be easily felt 2.5 cm. (1 inch) below the border 
of the ribs, and on percussion the dulness reached as high as the seventh rib in the 

Fig. 111. 




Typhoid fever. Male, 5 years old. 

axillary line. The enlargement of the spleen and the lower border of the ribs are marked 
in black in Fig. 111. The upper border of the splenic dulness is marked by a broken 
line, and the figure 7 marks the seventh rib. The blood showed no leucocytosis. 
The pupils reacted equally to light. The expression of the child's face was apathetic, 
and he took very little notice of anything. An examination of the urine showed the 
color to be normal, the reaction neutral, the specific gravity 1026, and that there was 
a slight trace of albumin. The sediment showed occasional hyaline and fine granular 
and fibrinous casts. A Widal reaction was not obtained. 

On the third day after entering the hospital, the eighth day of the disease, the 
child became very stupid and sometimes delirious. There was a slight cough. On 
the twelfth day of the disease the child cried out at times, and was delirious. The 
skin was dry and hot. There were no more rose-colored spots. There seemed to be 
slight tenderness in the lower iliac fossa, but there was no gurgling. On the fifteenth 
day of the disease the temperature began to fall by lysis, and the child began to be 
fretful. On the eighteenth day the temperature became normal. By the twenty-first 
day the child seemed bright, and was playing with its toys. The pulse was stronger. 
One week later it was sitting up in bed, and had a strong pulse and a good appetite. 
A few days afterwards it was up and about the ward, perfectly well. The following 



458 



PEDIATRICS. 



chart shows the temperature, pulse, and respiration from the fifth day of the child's 
illness until convalescence was established on the twenty-fifth day. 

The following notes and plate (Fig. 112) were given to me by Dr. S. S. Adams, of 
Washington, and occurred in an infant two years old. In this case the irregularity of 
the temperature curve and the prominent symptoms of cerebro-spinal irritation ren- 
dered the diagnosis so obscure that typhoid fever was not suspected until a few days 
before death. The post-mortem examination showed marked congestion of the entire 
brain, chiefly on the right side. The left hemisphere was covered with a glue-like 













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DAYS OF DISEASE 




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Typhoid fever. Male, 5 years old. 



substance which filled the sulci and was especially abundant around the Sylvian fissure. 
The heart was normal. The lungs showed marked hypostatic congestion. The liver 
was normal. The gall-bladder was empty and pale. The spleen was enlarged. The 
kidneys were normal. The stomach was congested. The mesenteric glands were en- 
larged and soft. The intestines contained a quantity of yellowish watery fasces. The 
lesions were in the ileo-colic portion of the intestine. There was thickening and 
ulceration of Peyer's patches, and to a less extent of the solitary follicles. 

Swelling of Peyer's patches and of the solitary follicles is not dis- 
tinctive of typhoid fever, as this condition frequently occurs from irrita- 
tions of various kinds. Fig. 113 represents a section taken from the 
intestine of a child. 



The macroscopic appearances of this intestine so closely simulated the early stage 
of typhoid fever that cultures were made from it by Dr. Prudden to settle this question. 
No bacilli were found. This condition is often found in children in acute non- 
typhoidal ileo-colitis. 



Fig. 112. 




Typhoidal ileocolitis, showing ulcers of colon. Female, 2 years old. 
U. S. Armv Medical Museum. 



Fig. 113. 




Enlarged Peyer's patches closely simulating the lesions of typhoidal ileo-colitis. Muc. Mem., mucous 
membrane ; Fol., enlarged follicles ; Mus., muscle. 



SPECIFIC INFECTIOUS DISEASES. 459 

TYPHUS FEVER. 

Typhus fever is an acute infectious disease, the cause of which has 
not yet been determined. In America typhus fever is an exceedingly rare 
disease, but in England it is well known to occur in children as well as in 
adults. According to Collie, out of 711 admissions to the Hunnerton 
Fever Hospital during a period from 1871 to 1880, 24 were under five 
years of age, 54 from five to nine years, and 113 were from ten to four- 
teen years. Buchanan has shown that typhus fever in early life is very 
mild, but that children are just as susceptible as adults. 

Symptoms. — The onset is acute. According to Ashby and Wright the 
attack begins with headache, pains in the limbs, drowsiness, sometimes 
vomiting, and rarely diarrhoea. The constitutional symptoms are of a 
severe type. The tongue is dry and coated, there are sordes on the 
teeth, and the gums bleed easily. On the fourth or fifth day the skin 
assumes a dusky, congested appearance, with an indistinct mottling. 
Sometimes there are rose-colored spots or maculae, larger than those 
seen in typhoid, appearing first, according to Collie, on the upper front 
portions of the chest, on the wrists, on the backs of the hands, and in the 
epigastrium. 

The temperature is usually continuously high, varying from 39.4° to 
40° C. (103° to 104° F.), and the pulse 120 to 130, and rather weak. The 
temperature usually becomes normal by about the eighth or tenth day. 

Prognosis. — The prognosis is usually good. Out of 191 children 
under fourteen years of age only two deaths took place, while the total 
mortality for all ages was 20 per cent. 

Treatment. — Especial attention should be paid to the hygienic sur- 
roundings, such as fresh air. sunlight, and warmth. Daily sponging and 
the free use of stimulants are indicated. The diet should be milk and 
broths until convalescence is well established. 

DIPHTHERIA. 

Diphtheria is an acute, highly infectious disease, due to the Klebs- 
Loeffler bacillus. It is primarily a local affection, the constitutional symp- 
toms being due not to the presence of the organism in the blood, but to 
the absorption of the toxins caused by the growth of the bacillus. 
Although the term diphtheria, derived from the Greek word dupdepa, 
implies a membrane, and the disease is usually accompanied by a pseudo- 
membrane, yet it must be understood that the disease is not diphtheria 
unless the specific germ is present. This germ may act with different 
degrees of intensity, and thus cause inflammation varying from a slight 
catarrhal condition to the most serious membranous one. In like man- 
ner, according as the form is mild or severe, there may be very slight 
constitutional symptoms or exceedingly serious ones. There is probably 
a concurrent infection with pyogenic cocci. These organisms produce the 



460 PEDIATRICS. 

secondary inflammations occurring in the disease, and also by their toxins 
give rise to additional constitutional symptoms. 

Etiology. — The Klebs-Loeffler bacillus was first described by Klebs 
in 1883, and later was more fully identified by Loeffler in 1884. Its 
most striking features, morphologically, are its variation in form and the 
irregularity in its manner of staining. It does not form spores. Welch 
and Abbott have shown that in fluids it may be killed by an exposure of 
ten minutes to a temperature of 58° C. (136.4° F.). Under favorable 
conditions it may remain alive for weeks, or even months, in fragments 
of dried membrane. 

The pathogenic cocci most frequently found in the concurrent infec- 
tions are the streptococcus pyogenes alone, or associated with the staphy- 
lococcus pyogenes aureus, the former being the most important in its 
action. There is no true diphtheria where the Klebs-Loeffler bacillus is 
not present, but its presence in a healthy throat does not constitute the 
disease diphtheria, although the individual may be the source of infection 
to others. It is undoubtedly a contagious disease of local origin, and it 
does not originate spontaneously. The contagium of diphtheria is con- 
tained chiefly in the secretions of the throat and nose, and is communi- 
cated usually by direct or indirect contact, and not, as a rule, by the air. 
The area of infection is not so great as in scarlet fever. It is not found 
in the urine and faeces. Sewer gas and confined impure matter of any 
kind may act by weakening the resistance of the body to the action of the 
bacilli, or, by producing a benign lesion in the throat, may offer a suit- 
able nidus for the invasion of the bacillus. It is now, however, con- 
ceded that imperfect drainage and unsanitary conditions should not be 
considered important factors in increasing the frequency of the disease. 
Animals, such as cows, cats, dogs, and pigeons, may have diphtheria, and 
be a source of infection to those brought in contact with them. There is 
no positive evidence that the milk of cows affected by diphtheria contains 
the germs of the disease, but the probability is that the milk in some of 
these cases may be contaminated by the hands of the milkers. The cases 
in which the pharynx and nose are affected are the most contagious on 
account of the secretions. Generally an unhealthy condition of the 
mouth, nose, or throat predisposes to the disease, as a lesion of the 
mucous membrane is necessary for its entrance. The bacilli will not 
grow on an intact mucous membrane. An abrasion must be present for 
them to develop. 

There is a non-virulent form of the diphtheria bacillus which differs 
in a number of respects from the virulent form, both in its culture pecu- 
liarities and in its method of staining with Hunt's differential stain, and 
also with Neisser's stain. 

Although diphtheria may occur at any age, it is rarely met with in 
early infancy. It is most commonly seen from the second to the fifth or 
sixth year. It may occur more than once in the same individual. 



SPECIFIC INFECTIOUS DISEASES. 461 

Pathology. — The lesions of diphtheria are due to the local action of the 
Klebs-Loeffler bacillus and associated bacteria, and to the absorption of 
toxins produced by the bacteria. The most constant lesion is a pseudo- 
membrane, produced by the local action of the bacilli in the upper air- 
passages, and due to exudation and coagulation necrosis. The exudation 
coming from the vessels of the tissue beneath the membrane meets the 
necrotic tissue containing a fibrin ferment, and coagulation takes place, 
the fibrin of the coagulum being intimately associated with the necrotic 
epithelium. The bacilli can also produce other lesions, such as simple 
inflammation, necrosis without membrane formation, and even abscess. 
There is no pathological condition directly characteristic of the action of 
the Klebs-Loeffler bacillus, and the same anatomical conditions may be 
caused by other bacteria, and even by irritants. The process may be 
simply a catarrhal inflammation, which does not go on to the formation 
of a pseudo-membrane. 

The primary infection in diphtheria is most commonly in the throat, 
from which the bacilli may extend into the adjacent mucous surfaces, pro- 
ducing, in some cases, membrane formation, in others only simple or puru- 
lent inflammation. They may also extend into the nose, producing 
nasal diphtheria, or along the Eustachian tubes into the middle ear, or 
from the nose into the accessory sinuses, downward into the trachea 
and air-passages, or into the oesophagus and stomach. There are certain 
differences in the membrane formation due to the anatomical character 
of the tissue. Thus the membrane in the pharynx clings tightly to the 
surface, while in the trachea and lower passages it is easily removed. 

The extension of the bacilli into the lungs may produce a membrane 
formation in the smaller bronchi, areas of broncho-pneumonia or even 
abscesses. The pathological process may be further modified by the 
association with the Klebs-Loeffler bacillus of the common pathogenic 
cocci, and it is difficult to determine exactly the part which these various 
organisms play in the production of the local lesions. It is certain, how- 
ever, that the lung lesions which are ordinarily attributed to these asso- 
ciated organisms may be produced by the Klebs-Loeffler bacillus alone. 

The membrane in diphtheria is usually of a peculiar grayish-white 
color, and, as a rule, cannot be easily detached ; in some cases, on the 
contrary, it may be white and easily separated. It sometimes assumes, 
early in the disease, a gangrenous appearance, which shows that the case 
is serious. Nasal diphtheria is characterized by a profuse nasal discharge, 
and often by a membrane. Transmission of the germ of the disease from 
the nose to the eye is infrequent, and does not always result in the forma- 
tion of a false membrane. Frequently the pharyngeal inflammation ex- 
tends through the Eustachian tube, causing inflammation of the middle 
ear, and in these cases a membrane may be formed. The membrane 
may extend downward to the larynx, causing marked dyspnoea. Below 
the vocal cords the membrane is not very firmly attached, and is fre- 



462 PEDIATRICS. 

quently coughed up. If death occurs late in the disease in apparent con- 
valescence no macroscopic lesions, as a rule, are found. Microscopic ex- 
amination of the nerves, however, often shows marked degeneration of 
the nerve tissue. 

The internal lesions of the disease are not due to the presence of the 
bacilli but to the action of the toxic substances which are absorbed from 
the places where the bacilli are growing. These lesions consist chiefly in 
diffuse, degenerative changes, and in intense local processes, also of a de- 
generative character. The organs most commonly affected by these 
lesions are the kidneys and the lymph-nodes. The adjacent lymph-nodes 
are apt to be swollen, and on microscopical examination they often show 
small foci of cell-necrosis ; similar, smaller necrotic foci may be found 
in other parts of the economy, as in the liver, and are due to absorp- 
tion of toxins. There is also a general lymphatic hyperplasia, which is 
relatively greatest in the abdomen. The kidneys ordinarily show only 
parenchymatous degeneration, but in a few cases of concurrent infection 
may present acute lesions. Hemorrhages into the serous membranes are 
often met with, and the organs in general show degenerative changes due 
to action of the toxins. Endocarditis is rarely seen. Catarrhal bronchitis 
and broncho-pneumonia frequently complicate diphtheria, and are caused 
by the inspiration of the pyogenic cocci as well as by the invasion of the 
Klebs-Loeffler bacillus itself. 

Incubation. — The time which elapses after exposure to the infection 
until the first symptoms develop may be only twenty-four hours ; on the 
other hand, it may be two or three days. This period of incubation is a 
very indefinite one, since the interval between the access of bacteria to 
the mucous membrane and the time when the absorption of the toxins 
becomes apparent depends upon whether the tissues of the mucous mem- 
brane are vulnerable. Thus, it is probable that the Klebs-Loeffler bacillus 
may exist in the mouth for an indefinite time without infecting the indi- 
vidual. 

Symptoms. — Diphtheria must be considered a local disease at the onset, 
and the symptoms that occur later are, like the secondary pathological 
lesions, the result of the absorption of the toxin caused by the growth of 
the bacillus. There may be mild forms of diphtheria almost without con- 
stitutional symptoms. The severe form of diphtheria is attended by grave- 
general prostration, cardiac depression, and anaemia, is frequently compli- 
cated with broncho-pneumonia and nephritis, and may be followed by 
localized or general paralysis. The constitutional symptoms are not due 
to the presence of the Klebs-Loeffler bacillus in the blood. 

The prodromal symptoms of diphtheria are not especially typical.. 
They may be acute in character, or very mild and of a subacute variety. 
In young children there may be in the onset of the disease a slight 
convulsion. In certain cases, according to McCollom, a peculiar dark-red 
appearance of the mucous membrane of the mouth is seen, which is- 



SPECIFIC INFECTIOUS DISEASES. 463 

quite characteristic. There is apt to be a sensation of chilliness, some 
heightening of the temperature, and more or less pain in the back and 
limbs. There is nothing, however, to distinguish this stage from many 
other affections of children, such as simple tonsillitis. The child may 
often complain of discomfort on swallowing, and on examining the throat 
the fauces are found to be reddened. In from twelve to twenty-four 
hours, however, a more typical appearance will be seen in the throat. A 
white or grayish-white pseudo-membrane, commonly appearing first on 
the tonsils, develops, and on the second or third day extends to the 
soft palate and uvula. It may also extend backward to the pharynx. 
During this stage the throat becomes much swollen and the tonsils con- 
siderably enlarged, so as almost to meet at times in the median line. 
The diphtheritic membrane is usually firmly adherent to the mucous mem- 
brane, and, as the case progresses, assumes a brownish or yellowish-gray 
color, sometimes becoming gangrenous, with an extremely foetid odor. A 
profuse nasal discharge in severe cases may appear at this stage, and, if 
the patient becomes septic, spots of ecchymoses, which are of grave im- 
port, appear on various parts of the body, and are usually significant of a 
fatal issue. Listlessness is present, but delirium of an active type is not 
common. An efflorescence resembling scarlet fever may appear in a still 
later stage. In addition to these lesions in the throat, the cervical glands 
are usually involved and become considerably swollen. The child, as a 
rule, shows grave constitutional symptoms. The temperature is not 
characteristic. It is usually not especially high, and ranges from 38.3° to 
38.8° C. (101° to 102° F.). It may, however, rise to 40° C. (104° F.). 
A subnormal temperature is more serious than a moderately elevated one. 
The pulse is somewhat increased in rapidity, and is weak in proportion 
to the severity of the disease, but does not always correspond to the tem- 
perature ; sometimes it is very slow. The slow pulse is indicative of the 
action of the toxin on the nervous centres, as well as to the weakness of 
the ventricles. Diarrhoea is a frequent but not a constant symptom. 
Loss of appetite, nausea, and vomiting frequently occur. 

In cases of a mild type the symptoms abate towards the end of the 
first week, the pseudo-membrane separates, leaving a raw surface behind 
it, the neck becomes less swollen, and the child feels much better. It is, 
however, usually left in a prostrated condition for a number of weeks ; 
and even in these mild cases the toxic effects of the disease may show 
themselves in the form of a neuritis with an accompanying paralysis many 
weeks after the diphtheria has run its course. There may also, even in 
mild cases, be a slight discharge from the nose, owing to the inflamma- 
tion of the posterior nares. Slight albuminuria is not infrequent. A 
very prominent symptom in all forms of diphtheria may be cardiac weak- 
ness. In some cases the child dies suddenly without any warning, or 
death may have been preceded by attacks of semi-collapse. In other 
cases there may be a weak intermittent pulse, which continues through- 



464 PEDIATRICS. 

out the disease and during convalescence. Under these circumstances the 
child should be considered to be in a critical condition, as death is likely 
to occur suddenly. 

The following case represents one of the milder forms of diphtheria : 

A boy, five years old, had been sick four days. His pulse was somewhat rapid, 
but of good strength. His respirations were slightly increased. There was no thoracic 
retraction. There was a slight discharge from the nose, and the cervical glands were 
somewhat enlarged. He took his nourishment well, and seemed in a very fair condi- 
tion. The urine contained a small amount of albumin. An examination of the throat 
showed small patches of grayish-white pseudo-membrane on the upper part of the left 
tonsil, and corresponding to the left arch of the soft palate. This is represented in 
Plate XL, facing page 620. The membrane had also involved the right side of the 
uvula, the right arch of the soft palate, and the side of the right tonsil pointing towards 
the median line. There was also a patch on the right tonsil and on the posterior wall 
of the pharynx. The tonsils were moderately enlarged and reddened, and the mucous 
membrane of the soft palate was considerably inflamed. When lesions of this character 
and description are seen in the throat, there can seldom be any doubt as to the clinical 
diagnosis of diphtheria, and a bacteriological examination should at once be made. 
In this case a culture made on Loeffler's blood-serum of a shred of membrane taken 
from the throat showed the presence of the Klebs-Loeffler bacillus and a large number 
of streptococci. 

Variations in Type. — There are a number of variations which occur 
both in the severity of the disease and in the locality which is first 
attacked or principally invaded. 

Atypical Infections of the Throat. — In some epidemics the Klebs- 
Loeffler bacillus seems to be far more virulent than in others, and in 
some individuals it produces much more serious symptoms than in 
others. The severity of the attack does not always depend upon the 
extent of the pseudo-membrane. In general, the severity of the cases 
depends on three factors : (1) the virulence of the bacteria, (2) the local 
resistance, and (3) the general resistance. A number of what may be 
called atypical cases have been observed and carefully studied, especially 
by Koplik, in which no pseudo-membrane was detected and in which the 
morbid appearances in the throat were those of a simple catarrh or fol- 
licular tonsillitis. The virulent Klebs-Loeffler bacillus was detected in 
these cases, and other children infected by them presented the typical 
local lesions of diphtheria. 

Malignant Forms of Diphtheria. — In addition to these mild cases, the 
Klebs-Loeffler bacillus at times produces a most malignant form of diph- 
theria. In these cases the child either shows a fairly mild form of the 
disease for a few days and then suddenly develops the severe form, or it 
may be attacked at once by very severe symptoms. It becomes dull ; 
the temperature is either slightly raised or may rise to 39.4° or 40° C. 
(103° or 104° F.), or higher; the pseudo-membrane spreads rapidly; 
there may be a dusky efflorescence on the skin, simulating closely that 
which I have described in the malignant form of scarlet fever. There 



i & j 



SPECIFIC INFECTIOUS DISEASES. 465 

may also be a purpuric condition of the skin. The picture of these septic 
cases is very characteristic. There is a peculiar, sweetish odor to the 
breath. There are cyanosis and a marked waxy pallor. There are 
hemorrhages from the throat and nose, with a profuse muco-purulent 
discharge from the latter. The cervical glands are often enormously en- 
larged. The membrane has been known to extend in all directions, and 
sometimes even through the Eustachian tubes to the external ears. All 
degrees of severity are met with between the mild and malignant types 
of diphtheria. The membrane, instead of extending upward to the naso- 
pharynx, as occurs in the malignant cases just spoken of, may spread 
downward, attacking the epiglottis and the larynx, and cause serious 
obstruction. The pseudo-membrane most commonly appears first on the 
tonsils, thence spreading to the soft palate and to the uvula. The disease 
may, however, begin in the mucous membrane of any part of the mouth, 
nose, or throat. 

Xasal Diphtheria.— Diphtheria sometimes begins in the nose and 
spreads no farther. In these cases the disease is usually of a mild type, 
but it is infectious. The condition is especially liable to be overlooked, as 
the child for one or two days may show merely the symptoms of fever, 
malaise, loss of appetite, and a discharge from the nose. On examining 
the nose carefully, however, a pseudo-membrane will often be found. It 
is, therefore, very important in cases of this kind to have a bacteriological 
examination made, and to isolate the child until it is determined that the 
Klebs-Loeffler bacillus is not present. These cases are a prolific source 
of infection to the community at large, for even when antitoxin has been 
given it does not kill the bacilli, although it may stop the nasal discharge. 

When the naso-pharynx is affected, either primarily or secondarily 
through the nares or the pharynx, the constitutional symptoms are, as a 
rule, marked. This is in all probability accounted for by the great mass 
of absorbents in the naso-pharynx, where absorption takes place so easily 
that general septic poisoning quickly follows. When the naso-pharynx 
is attacked by diphtheria, we usually meet with the most fatal results. 

Laryngeal Diphtheria. — In some cases the Klebs-Loeffler bacillus pro- 
duces its effects first on the mucous membrane of the larynx. In these 
cases the mucous membrane of the nose and pharynx may never show 
any evidence of a pseudo-membrane. The first symptom, as a rule, is a 
cough of a harsh, ringing nature. The temperature may or may not be 
raised. As the toxic absorption is slight, on account of the locality 
affected, the constitutional symptoms are correspondingly mild. The 
child's symptoms are those resulting from laryngeal obstruction. There 
is dyspnoea, with retraction of the intercostal and supraclavicular spaces, 
and later of the epigastrium and the lower chest. This is accompanied 
by an increasing cyanosis. The child is very restless, is forced to sit up 
in order to breathe, and, for the same reason, bends forward with its head 
back. In these extreme cases, unless relief is speedily afforded, the child 

30 



466 PEDIATRICS. 

soon dies of suffocation. In another set of cases a slower form of suffo- 
cation may result from the extension of the membrane downward to the 
bronchi, while in still another set death may result from a complicating 
broncho-pneumonia. 

In diphtheria of the larynx there may be laryngeal stenosis, and yet 
no membrane be visible, and the cultures taken during life may be nega- 
tive. In almost every instance, however, these cases are shown to be 
diphtheria at the autopsy. Streptococci may cause a membrane in the 
air-passages, but a membrane of such an origin, as a rule, is not suffi- 
ciently tough or thick to impede respiration. Attacks of laryngeal dys- 
pnoea may occur very suddenly, even in mild cases of diphtheria. 

Complications and Sequelse. — There are a number of complications 
which arise in diphtheria besides those of laryngeal stenosis and cardiac 
weakness. The most serious of these are broncho-pneumonia and acute 
nephritis. 

The form of pneumonia which complicates diphtheria is broncho-pneu- 
monia, which is produced not only by the Klebs-Loeffler bacillus, but by 
pyogenic cocci which have been inspired. Broncho-pneumonia is most 
frequent and most fatal in laryngeal cases which have been operated upon. 

Albuminuria is so commonly met with in both the mild and the severe 
cases of diphtheria that it should be considered as a part of the disease 
rather than as a complication ; as a rule, the greater the amount of albu- 
minuria the more severe the case. When acute nephritis complicates 
diphtheria it is not usually accompanied by oedema or anasarca. 

Otitis media, occurs frequently. Among the more common sequelae 
are secondary ancemia and chronic naso-pharyngeal catarrh. The most 
common and serious sequela of diphtheria is & peripheral neuritis, with its 
accompanying paralysis. This paralysis often does not appear until con- 
valescence has been established, perhaps in the third or fourth week from 
the time of the attack. It may show itself in the form of a palatal pa- 
ralysis of such an extent as not only to cause a nasal voice but to allow 
the passage of fluids through the nose. The child may die of inanition 
from inability to swallow, and may require to be fed with the head low- 
ered or by the stomach-tube. Inability to read, dilated pupils, and double 
vision may arise from ocular paralysis. There may also be a more gen- 
eral distribution of the paralysis, the child only being able to raise its 
head or move its limbs to a limited extent. Again there may be a pe- 
ripheral neuritis with marked pain. In the more severe cases the lower 
extremities are affected, and the knee-jerks are absent. When the limbs 
are involved the electrical reactions are the same as in peripheral neuritis 
from other causes. 

Diagnosis. — The local lesions produced by the Klebs-Loeffler bacillus 
may be merely a catarrhal inflammation or those of a follicular ton- 
sillitis. All such conditions, therefore, should be looked upon with sus- 
picion until the absence of the Klebs-Loeffler bacillus has been demon- 



SPECIFIC INFECTIOUS DISEASES. 467 

strated bacteriologically. Although a membranous laryngitis may be due 
to other causes than the Klebs-Loeffler bacillus, yet this is so rare that 
every case of primary membranous laryngitis should be considered to be 
diphtheria until it has been proved that it is not. A decisive diagnosis of 
diphtheria in any case can only be made by determining the presence of 
the Klebs-Loeffler bacillus. 

Recognizing that the same pseudo-membranous condition in the throat 
may occasionally be produced by pyogenic cocci as well as by the Klebs- 
Loeffler bacillus, the clinical diagnosis of a typical case of diphtheria is 
often difficult. A provisional diagnosis of diphtheria should be based 
upon the appearance of the throat of a pseudo-membrane which usually 
appears first on the tonsils, and has a tendency to spread to the uvula, 
soft palate, and pharynx. When in addition to this a nasal discharge 
is present, and the glands of the neck are much enlarged, a picture is 
presented which is not shown by any other disease. The most common 
difficulty met with clinically is in distinguishing between cases of acute 
follicular tonsillitis and diphtheria. In taking a culture, as has been 
pointed out by McCollom., a source of error in results is that the swab or 
platinum needle is rubbed over the surface of the membrane, a locality 
where the organism is most likely to die. The edge or, if possible, the 
under surface of the membrane are the proper places from which to take 
cultures. Cultures should also be taken from the secretions of the mouth 
and from the nasal discharge. Antiseptic gargles and applications should 
not be used a short time before the culture is taken. 

Efflorescences of urticaria and various forms of erythema may follow 
antitoxin, and even ecchymoses. Efflorescences may occur resembling 
scarlet fever and measles, often so closely that the most careful examina- 
tion and consideration of the symptoms are necessary, and even then the 
differential diagnosis is often impossible. Scarlet fever is differentiated by 
the presence of fever, vomiting, and the characteristic appearance of the 
throat and tongue ; measles by the absence of catarrhal symptoms and 
from the fact that the antitoxin efflorescence, as a rule, first appears on 
the extremities. The efflorescence from antitoxin may for a few days 
render the patient uncomfortable, but the symptoms pass off just as an 
urticaria does when resulting from one of its exciting causes. 

Prognosis. — Diphtheria is an extremely fatal disease, especially in the 
septic and obstructive cases. The mortality varies decidedly in different 
epidemics and according to the age. The mortality is greatest in children 
under two years of age, but has been lessened in cases in which the anti- 
toxin treatment has been thoroughly used. In the acute stage death may 
occur either from laryngeal stenosis or by the toxin generated from the 
growth of the bacillus. In the later stages or during convalescence it 
may be due to the action of the toxin on the nervous centres. Thus paral- 
ysis of the pneumogastric nerve with obstinate vomiting and heart failure 
is a frequent cause of death, occurring during apparent convalescence. 



468 PEDIATRICS. 

The symptoms which make the prognosis especially unfavorable are the 
extension of the membrane to the naso-pharynx or the larynx, profuse 
nasal discharge, marked septic odor, extensive glandular enlargement, 
hemorrhage from the nose or into the skin, a high grade of albuminuria, 
broncho-pneumonia, and a weak heart. Morse, in an extensive study of 
the leucocytosis of diphtheria, has shown that it has no prognostic value. 
In cases of post-diphtheritic paralysis the prognosis is good, as they almost 
invariably recover. The prognosis in all cases of diphtheria is uncertain 
and should be given with caution, and no case of diphtheria should be 
considered benign, for at times in certain mild cases serious symptoms 
of paralysis may arise, and death from heart failure is liable to occur at 
any stage of the disease. A child who has had diphtheria is liable to 
suffer from the deleterious effects of the disease for months and even 
years. Before antitoxin was used the mortality from diphtheria in the 
City Hospital was 50 per cent. Since its use in a series of 4500 cases in 
the diphtheria wards of the Boston City Hospital the mortality has been 
reduced to 13 per cent., and when the moribund cases, which numbered 
179, by which are meant those dying within twenty-four hours after ad- 
mission to the hospital, are deducted the mortality was about 10 per cent. 

Prophylaxis. — All patients with diphtheria should be isolated until 
the Klebs-Loeffler bacillus has disappeared from the nose and throat. The 
time when this occurs varies from a few days to a number of weeks. 

In order further to protect the community, all cases of sore throat 
should be examined, and if the Klebs-Loeffler bacillus is found the patient 
should be isolated. It is especially necessary to carry out this precaution 
in schools, where the conditions are so favorable for the spread of the 
disease. 

The throats and noses of all persons exposed to diphtheria or caring 
for diphtheritic patients should be repeatedly examined for the Klebs- 
Loeffler bacillus, and if this is found they should be given immunizing 
doses of antitoxin, the amount and frequency of the doses to be modified 
as our knowledge increases. If the Klebs-Loeffler bacillus is found in 
these individuals, they should be isolated so long as the bacillus is pres- 
ent. To shorten the period of isolation, mild antiseptic gargles or douches 
should be employed. It is very important to keep the teeth in good con- 
dition as a prophylactic measure, as well as the mucous membrane of the 
nose and throat. Whether the isolation of healthy persons who have the 
Klebs-Loeffler bacillus in their throat or nose is advisable or not is still a 
mooted question. Much confusion has arisen because of the so-called 
pseudo-diphtheritic bacillus. The weight of evidence at present, however, 
goes to show that it does not exist, and that the bacteria described are 
merely Klebs-Loeffler bacilli of diminished virulence. At any rate, even 
if the pseudo-diphtheritic bacillus exists, it is so rare that it may be 
safely excluded in clinical work. The fact that the Klebs-Loeffler bacilli 
found in healthy throats may not be virulent is not an argument against 



SPECIFIC INFECTIOUS DISEASES. 469 

isolation, because it is well known that a non-virulent form may become 
virulent when transferred to a different soil. Examinations of many 
healthy throats have shown that the Klebs-Loeffler bacillus is a very rare 
inhabitant of the normal throat, and that when it is present diphtheria 
often develops later. Theoretically, therefore, although it may be impos- 
sible or inadvisable practically, it would seem wise to consider the Klebs- 
Loeffler bacillus virulent until it has been proved to be non-virulent, and 
to consider its presence a source of danger to the community until it is 
proved not to be. 

When an individual has been exposed to the contagium of diphtheria, 
immunization can be accomplished by the injection of antitoxin in doses 
varying according to the age. Thus, at six months the immunizing dose 
for infants is 300 units, and for older children 400 units. The immuni- 
zation lasts for from twenty-eight to thirty days. 

The length of time before a child who has had diphtheria may cease 
to be a source of contagion should be determined by three consecutive 
negative cultures from the nose and throat with twenty-four or forty-eight 
hour intervals. 

The greatest care should be taken both by the physician and the nurse 
not to become infected themselves by the secretions from the mouth and 
nose of the patient. Especial care should be taken to avoid getting these 
secretions into the eyes. It is probable that with extreme care there is 
not much danger of the spread of diphtheria in a household, as we know 
its tendency is not to disseminate itself in the surrounding atmosphere, 
hence it is likely that with proper precautions it can be confined to the 
room in which the child is sick, and that if the epidemic extends beyond 
this room it has been carried directly by the hands or clothing of the 
nurse or physician. 

The room should be cleared of hangings and all stuffed furniture,- car- 
pets, and clothes. The hands of the attendants should be disinfected. 
No handkerchiefs should be used ; pieces of cotton cloth, which can be 
destroyed by fire, are to be preferred. Discharges should be disinfected 
with carbolic acid 1 to 200 ; mattresses, blankets, and utensils should be 
steamed. The floors and woodwork should be washed with corrosive 
sublimate 1 to 500. Books and toys should be destroyed, as there is no 
way of disinfecting these articles. Upholstered furniture should be im- 
mersed in boiling naphtha for two or three hours. The boiling-point of 
naphtha is 79.4° C. (175° F.), and is lower than the melting-point of glue. 
The vapor of formaldehyde is one of the most valuable germicides. Gen- 
eral disinfection of the room is described in the disinfection of scarlet 
fever, page 562. Pure air and plenty of sunlight are the most effective 
germicides. It is important to isolate doubtful cases, especially when the 
symptoms are associated with a profuse nasal discharge. 

Treatment. — The treatment of diphtheria consists (1) in attending to 
the hygiene and to measures directed to the general condition ; (2) in the 



470 



PEDIATRICS. 



administration of remedies, either by the skin or by the mouth, to combat 
the toxin which is producing the constitutional symptoms ; (3) in local 
applications to the nose, throat, or larynx ; and (4) in operative measures 
to relieve obstruction in the larynx. 

General Hygiene. — One of the most important parts of the treatment 
of diphtheria is the management of the room in which the patient is kept 
during the progress of the disease. It is known that pathogenic organ- 
isms, such as the Klebs-Loeffler bacillus, do not thrive where they are 
exposed to sunlight and fresh air. The room should therefore be 
thoroughly ventilated, and fresh, pure air should be allowed to come 
continuously into it. It should also be one which has a sunny exposure. 

Stimulation. — In any treatment directed to the cure of diphtheria in 
young children, we must remember that the disease is so exhausting that 
the treatment, as a rule, should be forced upon the child as little as possi- 
ble. Any physical exhaustion produced by the treatment is to be con- 
sidered serious in young children. Diphtheria is such a depressing dis- 
ease that alcohol should be given from the onset, and the amount should 
be relatively large. Either whiskey or brandy are valuable stimulants. 
For a child, one or two years old, it is well to begin with 7.50 c.c. (2 
drachms) every four hours, watching the pulse and general condition. 
When there are indications of beginning heart failure, digitalis is indicated 
early in the disease, and strychnine later. When there is collapse, nitro- 
glycerin should be given. Atropine is recommended as sometimes giving 
great relief when much mucus collects in the air-passages. 

The following table has been arranged to show the small and large 
doses of digitalis, strychnine, nitro-glycerin, and atropine, which may be 
used at different ages : 

TABLE 63. 



Age. 


Tincture 
Digitalis. 


Strychnine. 


Nitro-Glycerin. 

1 per cent. Solution. 

(1 minim = T J„ grain.) 


Atropine. 




Minims. 


Grain. 


Minims. 


Grain. 


3 months. 


1 to i 

To lo 2 


2000 t0 ToV 


j\ to ^ 


3 00 tO j-^q-q 


6 months. 


To to I 


1 to 1 

T500 l ° 500 


A t0 tV 


T5oo to xq 1 ^ 


9 months. 


\ tol 


l to l 
TO 00 l ° 3 


A t0 tV 


T"5"00 tO y-^ 


12 months. 


I toll 


sio to 2T0 


A to i 


T^o to -5-^ 


2 years. 


i to 2 


1 to 1 

-5-00 to T5~0 


tV to i 


lis to 2T 7 


3 years. 


i to 3 


1 to 1 

3 tU 10 


tV to 1 


1 to 1 
■5^0 IO 207 


4 to 10 years. 


1 to 5 


1 to 1 

200 l ° 60 


\ to f 


1 to 1 


10 to 12 years. 


3 to 8 


1 to 1 
To"o" lU 40 


1 tol 


1 to 1 

200 lo Tinr 



Serum- Therapy. — The treatment which, according to our present 
knowledge, is most efficacious in diphtheria, is essentially comprised un- 
der what is called serum-therapy. 



SPECIFIC INFECTIOUS DISEASES. 471 

By serum-therapy is meant the treatment of the disease by injecting 
into the patient the serum of an animal which has been rendered immune 
to the special disease which is being treated by means of inoculation 
with the toxin of that disease. The serum taken from the animals which 
have been rendered immune to diphtheria has been called the antitoxin 
serum. The serum can be injected under the skin. The place selected 
should always be one on which pressure is not exerted when lying in 
bed. 

The dose of antitoxin serum of diphtheria should be from 1000 to 
3000 units, according to the age of the child and the severity of the 
disease. McCollom prefers the use of from 2000 to 4000 units. The 
unit is the same in all reliable preparations. 

The beneficial results of antitoxin are decidedly greater if the injec- 
tion is made in an early stage of the disease than if later, although even 
when administered late in the disease it sometimes produces wonderfully 
curative effects. When given early, within the first forty-eight hours of 
the disease, even when the membrane is spreading rapidly, and inflam- 
mation of the glands with general systemic poisoning has taken place, 
one injection will often arrest the disease. When improvement does not 
take place within six or eight hours, a second dose, and if necessary a 
larger one should be used. Thus, if the dose was 2000 units, after eight 
hours a second dose of 2000 or 3000 units should be given, the latter in 
the more severe cases. In these very severe cases even much larger 
doses may be given and at shorter intervals. 

The signs by which we know that the antitoxin serum has produced 
a beneficial result, are indicated by the improvement in the general con- 
dition of the patient, and the effect of the antitoxin on the pseudo-mem- 
brane, which is characteristic. The dose should, therefore, be repeated 
if the general condition and the throat do not improve in eight hours. 
If at the end of twenty-four hours the membrane has not begun to roll 
up at the edges, and the cervical glands have not diminished in size, and if 
a profuse nasal discharge with a septic odor is present, a third dose, and 
perhaps a fourth or fifth dose, may be required. When the antitoxin has 
produced its characteristic effect, the pseudo-membrane besides rolling up 
at the edges, ceases to spread, whitens, shrinks, shows a line of demarka- 
tion, and usually within the next three or four days becomes detached 
from the mucous membrane. 

The temperature sometimes rises after the injection of antitoxin, and 
in a few days falls to the normal by lysis. In the more severe cases a 
single injection of the serum does not work so quickly. In these cases 
the temperature falls usually by lysis after the second or third dose, and 
the pulse becomes normal two or three days after the temperature has 
fallen. The irregularities of the pulse are not so frequent in diphtheria 
since the antitoxin treatment has been employed. 

Antitoxin does not seem to destroy the bacilli in diphtheria, but to 



472 PEDIATRICS. 

have some special action on the tissue-cells. If the cells have been much 
damaged they do not respond, and this is an argument in favor of the 
early administration of antitoxin. The antitoxin, however, is not able to 
combat complications referable to secondary infection. It is not a fact 
that since antitoxin has been used the type of diphtheria epidemics has 
been less virulent, as has been suggested. 

The pains which occur during the course of diphtheria are probably 
forms of neuritis, and not the result of the antitoxin which has been 
given. The later forms of neuritis which occur two or three months after 
the disease has run its course have nothing to do with the administration 
of antitoxin. The arthralgia and efflorescences which occur during the 
disease may arise from the antitoxin, but are never serious, and, although 
the number of cases of neuritis arising in the course of diphtheria since 
the use of antitoxin is greater than before its use, they are rarely of a 
severe type, and seldom need cause any great amount of anxiety. Out 
of one million cases in which injections of antitoxin were given, only five 
deaths were reported which could be attributed to the effects of the anti- 
toxin. 

Albuminuria is one of the most constant symptoms of diphtheria. 
McCollom had the urine tested in two hundred cases before the adminis- 
tration of antitoxin, and in only ten cases was the amount of albumin in- 
creased after the administration of antitoxin, and these ten cases were of 
a severe type. There was no reason to suppose that the antitoxin had 
anything to do with the increase in the albumin. It is to be noted that, 
according to Baginsky's observations, nephritis may occur in mild cases 
of diphtheria as well as in severe cases. 

Antitoxin has no influence in preventing the later symptoms of 
paralysis and cardiac failure, excepting as prophylactic when given early. 

When there is a concurrent infection the antitoxin serum is less effec- 
tual, as it does not counteract the toxin absorption due to bacteria other 
than the Klebs-Loeffler bacillus. It is not safe to assume, however, that 
there is a concurrent affection because other bacteria are found in the 
throat. When the larynx is involved, with accompanying stenosis, the 
antitoxin serum is found to be very valuable, and has reduced the number 
of operative cases. The antitoxin has been found to have but little effect 
upon the length of time which the bacteria remain in the throat after the 
disappearance of the membrane. 

Antitoxin should be freely used in diphtheria of the eye. The pupils 
should be dilated with atropine, and the eye irrigated with a 2 to 4 per 
cent, solution of boric acid. The child, as soon as possible, should be 
placed in the hands of a skilled oculist. 

At the South Department of the Boston City Hospital, in 4500 cases, 
all of which had on an average at least two injections of antitoxin, no 
bad results were reported, and one patient had 28,000 units of antitoxin 
given to him and was discharged well. 



SPECIFIC INFECTIOUS DISEASES. 



473 



In connection with the antitoxin treatment no especial drugs given 
internally by the mouth are indicated. Of course, symptomatic treatment 
of any kind is not contra-indicated. 

Technique of Antitoxin Injection. — A sterilized glass syringe should be 
used, and the needle should be comparatively small. The part to be in- 
jected should be thoroughly sterilized with corrosive sublimate. A needle 
previously sterilized by boiling should be plunged into the tissues and the 
injection made slowly. The place of puncture should then be closed 
with sterilized gauze and collodion. 

Local Treatment. — The local treatment of diphtheria consists in thor- 
ough cleansing of the mouth and nose with warm non-irritating solutions, 
such as normal salt solution or boracic acid four per cent. All strong and 
irritating applications to the throat in diphtheria are harmful. The tech- 
nique of the local applications to the throat and nose is important. The 
most simple, efficacious, and safe method, and that which produces the 
least discomfort, is by irrigation. The same method — namely, by means 
of a fountain syringe — should be employed for either the throat or the 
nose, except that in the former a larger glass nozzle should be used than 
for the nose, and one which is sufficiently long to pass over the base of 
the tongue. The method of irrigation as employed in the Boston City 
Hospital and at the Willard-Parker Hospital in New York is shown in 
Fig. 114. 




Irrigation of t 



diphtheria. 



The child should lie on its side, and the water should be made to pass 
up one nostril and down the other until the stream runs clear. In some 
cases the child prefers to sit up while the irrigation is done. Ordinarily 
the irrigation should be used once in two or three hours, perhaps with 
longer intervals at night. If the child resists this treatment it may be 
advisable, in order to save its strength, to omit it for a time. This rule ap- 



474 PEDIATRICS. 

plies to all forms of local treatment. A similar method should be used 
for the throat, and is of great comfort to the patient. 

In the South Department of the Boston City Hospital irrigation of the 
throat is the routine treatment, and only in special cases is irrigation 
through the nose indicated. This is in order to avoid the passage of 
fluid infected by bacteria into the nasal end of the Eustachian tube, which 
might produce infection of the ear. 

Considerable suffering is at times occasioned by the enlargement of the 
cervical glands. These are best treated with flaxseed or ice poultices. 
The former, however, has a tendency to produce suppuration, and the 
latter in most cases is the best. 

When it is deemed advisable to use inhalations of vapors in stenosis 
of the larynx the following method may be employed, but it must be re- 
membered that the child should not be kept in this atmosphere continu- 
ously, and should be watched carefully to see if it is speedily relieved of 
the stenosis ; for if it is not, the continuous inhalation of steam in the 
comparatively small area of breathing-space which exists in the tent that 
is used for this purpose may of itself be detrimental to the child's re- 
covery, from lack of sufficient oxygen. When tracheotomy has been 
performed an atmosphere of steam is especially valuable. Dr. McCol- 
lom's experience at the South Department of the City Hospital is that 
the tent need never be used, and that it is better to intubate at once. 

The tent, as described by Dr. Northrup, who has used it so extensively 
in the Willard-Parker Hospital in New York, contains about fifty cubic 
feet of air. To extemporize a tent, a sheet is thrown over supports 
above the crib and allowed to fall over the four sides of the crib. The 
main point is to have a fairly large and tight enclosure. The apparatus 
for furnishing the steam must be free from the danger of upsetting and of 
setting the tent on fire. When there is a mild form of laryngeal stenosis, 
steam should be only moderately used, as the debility following a steam- 
bath is often great. Sometimes the steam will give more relief when it is 
medicated, but this is now considered very doubtful. 

Operative Treatment: Intubation; Tracheotomy. — When the antitoxin 
does not relieve the symptoms of stenosis, and when the progressive 
dyspnoea is not quickly controlled by steam, it is well not to delay opera- 
tive interference. In laryngeal stenosis operative interference is de- 
manded by intubation or tracheotomy. The indications are marked 
supra-clavicular, sub-sternal, and lateral thoracic retractions lasting for 
two or three hours and apparently increasing in severity, a cyanotic hue 
of the skin, either with or without such retraction, great restlessness, dila- 
tation of the alae nasi, and failure of strength, even if the other symptoms 
are not increasing or are absent. 

The following is the technique of intubation : The patient is wrapped 
firmly in a blanket, so that he cannot move his arms, and then placed in 
a horizontal position, with the head slightly raised. The mouth is held 



SPECIFIC INFECTIOUS DISEASES. 475 

open by the gag, with its jaws resting on the molar teeth. The gag 
should be on the left side. Care must be taken not to have the cheek 
injured by the gag, and special pains must be taken to prevent its slipping. 
The head should be steadied by the assistant who holds the gag. The 
operator takes the introducer in the right hand, with the index-finger 
around the hook on the under surface of the handle, the loop of silk 
passing over his little finger, and his thumb resting on the button on the 
upper surface of the handle. The index-finger of the left hand is then 
passed down to the epiglottis, which is hooked forward ; the tube is then 
passed into the mouth, with the handle well down on the chest of the 
patient; when the epiglottis is reached by the point of the tube, the 
handle should be given an abrupt turn, so as to bring the tube into a 
vertical position. As soon as the tube is well in the larynx, the button 
on the handle should be pushed forward, disengaging the obturator, which 
must now be removed, and the tube pushed into position by the index- 
finger. The loop of silk is passed about the ear and the gag removed. 
If the tube is in the larynx, the patient will immediately begin to cough 
with a peculiar sound, which, to be appreciated, must be heard. If the 
breathing becomes easier, if the cyanotic hue disappears, if the retraction 
of the thoracic walls diminishes, if the loop of silk does not shorten, we 
may be assured that the tube is in the larynx. 

After becoming satisfied that the operation has been properly per- 
formed, the gag is inserted a second time, the index-finger placed on the 
head of the tube, and one strand of the silk loop cut, so that it can be 
removed. It should be especially emphasized that the finger of the oper- 
ator must be a continuation of the posterior wall of the larynx, that the 
turn should be abrupt, and that no force must be used. If the tube is in 
the oesophagus, no cough will be heard ; there will be no relief in the 
breathing ; the silk loop will commence to shorten as the tube passes 
downward. 

In certain instances intubation does not give relief, and tracheotomy 
must be done. If the tube becomes clogged by membrane, as is some- 
times the case, it must be immediately removed. The first steps of an 
extraction are similar to those of an introduction. The extractor is passed 
into the lumen of the tube and the lever on the handle pressed so as to 
open the jaws, and the tube extracted by a reverse of the movements in 
introduction. Sometimes there is considerable difficulty in extraction, but 
by patience and gentleness the end can be accomplished. If the child 
coughs up and then swallows the tube, the accident may cause consider- 
able annoyance to the physician, yet it is not of serious import, for experi- 
ence has shown that the tube is passed by the rectum in from twenty-four 
to forty-eight hours, without causing discomfort. No definite rule can be 
given regarding the length of time that the patient should wear the tube. 
It is well to remove it at the end of the third or fourth day, but it is fre- 
quently necessary immediately to reinsert it. In some instances three or 



476 PEDIATRICS. 

four extractions and introductions may be required. The most favorable 
cases are those in which the child coughs up the tube at the end of the 
third day, and does not require reintubation. Relief should come in five 
minutes. A child which has been intubated needs more careful watch- 
ing than one in whom tracheotomy has been performed, as the acci- 
dents following intubation occur more suddenly and are more difficult for 
a nurse to meet. 

O'Dwyer's tubes are preferably used at the South Department for the 
purpose of intubation. 

Tracheotomy should be performed if, after intubation, relief of the 
breathing does not come even when the tube has been removed and re- 
placed again. It is extremely rare for tracheotomy to succeed when in- 
tubation has failed. 

Feeding. — After intubation the administration of food is often diffi- 
cult, and various methods can be employed. (Esophageal feeding is the 
safest way of administering food, and is one of the important points to 
be remembered when intubation has been performed. In nasal feed- 
ing there is considerable danger of producing irritation in the middle ear, 
not always, however, from the Klebs-Loeffler bacillus. The method of 
feeding with the head lowered (Casselberry) is not devoid of danger, from 
the possibility of inhalation pneumonia following inspired particles of 
food. Nutritive enemata of peptonized milk, with stimulants, may, when 
retained, be an important adjunct to the treatment. Enemata, however, 
are not often retained. Digitalis in the enemata may be used in cases in 
which heart failure is present. 

Treatment of Sequelce. In the treatment of post-diphtheritic paralysis 
strychnine is the most valuable drug. When there is marked palatal 
paralysis oesophageal feeding is exceedingly important. Electricity, espe- 
cially faradism, is also indicated. Secondary anaemia should be treated 
in the usual way, with iron, a carefully regulated diet, and by general 
hygiene. 

INFLUENZA (LA GRIPPE). 

Etiology. — Influenza is an acute, highly infectious disease. According 
to Leichtenstern, there are two forms of influenza. One form, which is 
known as epidemic influenza, is a pandemic disease, caused by Pfeiffer's 
bacillus, and characterized by great rapidity of extension, varying symp- 
toms, a special tendency to attack the respiratory mucous membranes, 
an acute onset, a high degree of infection, and a tendency to become 
endemic during a succession of years after its first epidemic outbreak in a 
community. 

The second form is the common endemic or pseudo-influenza, or catar- 
rhal fever, the etiology of which is unknown. 

Incubation. — The period of incubation is short, being usually under 
four days. One attack does not protect from another. 



SPECIFIC INFECTIOUS DISEASES. 477 

Symptoms. — The onset of influenza is usually very acute, and the 
symptoms are variable. At times they are the same in children as in 
adults, but in infants and young children the symptoms are often not so 
severe as in the adult, although they vary in different epidemics. It is a 
characteristic of epidemic influenza that it has no distinct group of symp- 
toms of its own. The symptoms are chiefly a catarrhal affection of the 
nose and throat, and frequently of the bronchi. These symptoms in young 
children are accompanied evidently by great discomfort, at times amount- 
ing to pain, in the limbs and body, although on account of the age of the 
patient it is impossible to determine whether much pain is present. 
Sometimes the only marked symptom is a heightened and irregular tem- 
perature, with marked apathy, and the disease may be so slight as to be 
recognizable only during an epidemic. In older children the symptoms, 
although, as a rule, not of so severe a type as in adults, are at times quite 
serious, especially if continuous vomiting occurs. Severe headache and 
delirium are present in some cases, and extreme emaciation, out of pro- 
portion to the fever or to the morbid conditions detectable on physical 
examination. Severe symptoms connected with the larynx and the 
lungs may also arise and rapidly disappear. 

In young infants, even when no complications arise, the apathy and 
prostration may become extreme, and death take place seemingly from 
the overwhelming intensity of the infection. 

In addition to the complications already mentioned, various forms of 
efflorescences may appear on the skin and render the diagnosis more diffi- 
cult. There is a tendency to the development of tuberculosis after influ- 
enza. Relapses and recurrent attacks are not uncommon, and it should 
be remembered that a reinfection at times seems to take place in the sick- 
room. Out of a large number of cases in children examined by Schloss- 
mann, albuminuria occurred in eight per cent., but nephritis was rare. 
Anaemia is a common sequela in young children. Leucocytosis in un- 
complicated influenza is not present. The mental disturbances so com- 
mon in adults and multiple neuritis are not marked sequelae in children. 

Variatioxs in Type of the Disease. — It is now generally recognized 
that there are distinct types of the disease. 

Respiratory Type. — In this, the most common form of the disease, 
the influenza bacillus may attack any part of the respiratory tract from 
the nose to the pulmonary alveoli, the symptoms increasing in severity 
according as the latter are approached. In the milder forms there are the 
usual symptoms of acute coryza, fever, and headache, but these symptoms 
are accompanied by a far greater degree of prostration than is met with 
in the ordinary attacks of catarrhal rhinitis. These milder cases, without 
complications, may last only a few days ; the temperature is usually mod- 
erate 38.2° to 39.4° C. (101° to 103° F.), but the prostration is marked. 
An annoying, persistent cough is commonly present. 

This form is sometimes much intensified, may last longer, have a 



478 PEDIATRICS. 

higher temperature, and show a greater tendency to complications, espe- 
cially in the development of otitis media and cervical adenitis. 

In another set of cases of the pulmonary type, the disease, instead of 
retrograding steadily, progresses, bronchitis develops, and the accompany- 
ing delirium and extreme prostration may simulate typhoid. This bron- 
chitis has no especial peculiarities, but in young children it assumes at 
times a very intense grade, reaching the finer bronchi and producing 
cyanosis and asphyxia. 

In certain instances an influenza pneumonia develops, depending 
either on the Pfeiffer's bacillus or on a mixed infection. This pneumonia 
is usually lobular, although rarely lobar. Generally, there are small areas 
of broncho-pneumonia diffusely scattered, and often giving rise to no other 
physical signs than scattered moist rales. The sputum in these cases of 
influenza broncho-pneumonia is never "rusty," but is muco-purulent 
and generally of a greenish-yellow color. A diagnosis can be made by 
finding the influenza bacilli in large numbers within the polynuclear leuco- 
cytes. The resolution of such a pneumonia is prolonged, ending by lysis. 
This class of cases is very serious, and much of the mortality of epidemic 
influenza arises from these pulmonary complications. The broncho-pneu- 
monia is of the ordinary type, although possibly more irregular than in 
other cases. 

Pleuritis may occur in the course of influenza, but is rather rare; 
when present, however, it is apt to become an empyema. 

Nervous Type. — In certain cases there may be no catarrhal symptoms 
but nervous symptoms of the most varied forms. Pains in all parts of the 
body and limbs, cerebral symptoms simulating meningitis, convulsions, 
delirium, opisthotonos, symptoms simulating pneumonia without, however, 
the physical signs of that disease, or a typhoid condition with weak, rapid 
pulse, a temperature of 40.5° to 41.1° C. (105° to 106° F.), and irregu- 
larity of the heart. - All these severe and alarming symptoms may pass off 
in two or three days and leave no trace of any of the simulated diseases, 
although the resulting prostration may last for a long period. 

Gastro-Enteric Type. — In this form of the disease the prominent 
symptoms are nausea, vomiting, abdominal pain, diarrhoea, and a ten- 
dency to collapse. 

The spleen is enlarged in a certain number of cases, and this, according 
to Osier, depends on the intensity of the fever. These symptoms may last 
only two or three days, and, as a rule, are not followed by an unfavora- 
ble result. 

Febrile Type. — The temperature in influenza is very variable, and, as 
stated by Osier, may, with its accompanying prostration, be the only 
manifestation of the disease. 

It may be remittent and associated with chills, or, on the other hand, 
may be of a continued type, and so prolonged as to simulate typhoid fever. 

Diagnosis. — The diagnosis of epidemic influenza is often difficult, un- 



SPECIFIC INFECTIOUS DISEASES. 479 

less influenza is present in the community, and is to be made by the care- 
ful elimination of other diseases, and the detection of Pfeiffer's bacillus, 
either in the secretions of the nose or in the sputum. The profound 
prostration out of proportion to the intensity of the disease is of great 
diagnostic value. In the early days of the disease it is often impossible 
to differentiate from pneumonia, malaria, the acute exanthemata, and 
meningitis, but later the differential diagnosis is made by the disappear- 
ance of the especial symptoms of these diseases, and the failure to find 
their special infecting organisms. The diazo-reaction is absent in influ- 
enza. 

Prognosis. — The disease in itself is not dangerous, but complications 
are especially liable to arise and make the prognosis much more serious. 
These complications are very numerous. They may be meningitis, otitis, 
ileo-colitis, broncho-pneumonia, and lobar pneumonia. The most com- 
mon and dangerous complication of influenza is pneumonia, which is 
usually a broncho-pneumonia, and is of serious import, especially if the 
child is debilitated at the time of the attack by some previous disease. 
The broncho-pneumonia of influenza is of more serious import than that 
arising from other causes, with the exception of infections due to tuber- 
culosis or diphtheria. 

Treatment. — In the treatment of epidemic influenza in infants and 
children I have found that drugs have very little effect upon the general 
discomfort caused by the pain or cough. Small doses of phenacetine, 0.06 
gramme (1 grain) once in three or four hours, with ten or fifteen drops 
of brandy, seem to yield as good results as any other mode of treatment. 
When there is severe and continuous vomiting, small doses of iced cham- 
pagne by the mouth, enemata of bromide of potassium, and, if neces- 
sary, hydrate of chloral, are indicated. The child should be kept in bed 
and isolated. The bronchial and nasal secretions should be disinfected. 
Stimulants are especially indicated when pneumonia is present, and 
strychnine is valuable as a heart stimulant. A high temperature, nervous 
and gastro-enteric symptoms, should receive the appropriate treatment as 
in other diseases. When the convalescence is prolonged, especially if the 
case has been one of the pulmonary type, or when there is a tendency to 
tuberculosis or to a recurrence of the attack, a change of climate is 
decidedly indicated and is frequently beneficial. The diet should be milk 
and beef tea. Careful feeding is very important after an attack of influ- 
enza, as there is often left a tendency to infantile atrophy. 

During the epidemic of influenza which occurred in Boston in 1891 I 
had under my care at the Infants 1 Hospital seven infants, varying in age 
from a few months to one and a half years, all of whom had epidemic 
influenza. Pneumonia occurred in two of the cases, and in both of these 
the infants died. The following charts (Charts 13 and 14) show the tem- 
perature of these cases during the course of the disease, and the rise 
when the infants were attacked with pneumonia. 



480 



PEDIATRICS. 



CHARTS 13 and 14. 





Influenza. 


Pneumonia. Days 


of Disease lnfiuetlza 


Pneumonia. 




F. 


1 


2 


3 


4 


6 


1 


2 


3 




























c. 

41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 

35.0° 


107° 
106° 
105° 
104° 
103 
102 
101° 
100° 

o 

99 

NORMAL 
TEMP. 

98 

97° 

96 
95 


M E 


M E 


M E 


M E 


M E 


M E 


ME 


M E 


M E 


M E 


ME 


ME 


M E 


ME 


M E 


M E 


M E 


M E 


M E 


M E 


M E 




























































cs 








































/ 


























-s: 
















/ 




















/// 


oj 












L 






























/ 


-A 


A 








I 






















/ 








Z_ 


V 


A 


/ 




r 










1 


/ 


/ 


/ 




































i 


/ 


/ 


/ 




































(Z 




f 


























































































































































































Infantile atrophy. Epidemic influenza. 
Pneumonia. Male, 4 months old. 


Previously healthy. Epidemic influenza. 
Pneumonia. Female, 3 months old. 




CHART 15. 


1 


Influenza 


Days of Disease Pneumonia 




W. 


3 


4 


5 


6 


7 


8 


9 


10 


l 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


C. 


107° 
106 
105 
104 
103 
102 
101° 
lOO 



99 

NORMAl 

TEMP 

98 



97 
96° 



95 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 
35.0° 
















































J 












1 


' 


/ 


' 




















~7 


A 


V 






/ 






4 


/ 


/ 






































i 


/ 


/ 


/ 


/ 


































i 


1 




/ 


/ 
































k 


V 










k, 




S 


















































































\ 




\ 






















































































' 







































































































































Epidemic influenza. Pneumonia. Recovery. Male, 16 months old. 



Another case of influenza was complicated on the eleventh day of the 
disease by a lobar pneumonia. 

The infant, sixteen months old, was attacked with catarrhal symptoms of the nose 
and throat, a slight cough, and a temperature of 40.5° C. (105° F.). The respira- 
tions were only slightly increased ; the pulse was rapid. Nothing abnormal was found 
on physical examination. The infant was very fretful, had no appetite, cried inces- 



SPECIFIC INFECTIOUS DISEASES. 481 

santly, and seemed to have considerable discomfort. On the ninth day from the onset 
of the attack the temperature fell to 39.1° C. (102.5° F.), and on the following day to 
38.6° C. (101.5° F.). On the evening of this day the infant, who had begun to be 
brighter and to notice its playthings, again seemed very sick. Its respirations in- 
creased in frequency, there was motion of the alae nasi, and the temperature rose to 
40.8° C. (105.4° F.). On the following day the temperature fell in the morning, but 
began to rise in the evening, and by the next day had reached 41.0° C. (105.8° P.). 
On this day, the thirteenth from the beginning of the attack and the third from the 
fresh invasion, marked flatness was detected in the right lower back, with bron- 
chial respiration and increased tactile and vocal fremitus. This area of flatness in- 
creased, and finally involved the whole lower lobe of the right lung. On the fourth 
day of this new invasion the temperature fell to 38.8° C. (102° F.) ; on the following 
day it rose to 39.7 C. (103.5° F.) in the evening, and in the next two days gradually 
fell to 37.2° C. (99° F.). On the following day it rose to 38.6° C. (101.5° P.), and 
in the next forty-eight hours fell gradually to 36.6° C. (98° P.). At this time the 
dulness began to disappear, moist rales appeared, the infant became much better, and 
in a few days, although very weak, seemed bright and well, and the physical signs in 
the lung had entirely disappeared. 

Chart 15 shows the temperature during ten days of the influenza, when a lobar 
pneumonia appeared and ran a course of five days, after which the temperature gradu- 
ally fell to the normal point. It is possible that this case was one of pneumonia from 
the beginning of the attack, but it showed all the characteristic symptoms of epidemic 
influenza, and no flatness was found in the lung until the infant had apparently re- 
covered from its influenza. 



MALARIA. 

Malaria is an infectious disease, transmitted from an infected human 
being by means of mosquitoes of the genus anopheles to another human 
being. There may be other sources of infection not yet determined. 

Etiology. — The specific infection of malaria is primarily shown in the 
blood in the form of certain micro-organisms which, like the amoeba coli, 
belong to the class of protozoa and inhabit the blood of the infected indi- 
vidual. The micro-organism of malaria has not been found in any part 
of the body except in the blood and within the blood-vessels, and malaria 
may therefore justly be said to be a disease of the blood. 

The work of Ross, Grassi, Bignami, Bastianelli, Daniels, and Koch has 
shown that the most important and very probably the only manner of 
infection in malarial fever is through the bites of mosquitoes of the genus 
anopheles, which, with man, form the regular hosts of the parasite. The 
malarial parasite, like the coccidia, has been shown to possess both an 
asexual and a sexual cycle. The sexual cycle takes place in the human 
body and ends in segmentation, each segment attacking a new red cor- 
puscle, and beginning again a new cycle as a fresh young parasite. Cer- 
tain bodies, however, when they reach full development, do not undergo 
segmentation. These are the large, full-grown, sometimes wrongly called 
"extra-cellular bodies" of the tertian and quartan parasites, and the 
crescentic and ovoid forms of the aestivo-autumnal parasite. When a 
mosquito of the genus anopheles bites an infected human being, certain 

31 



482 PEDIATRICS. 

of these forms, the male elements, develop flagella in the stomach of the 
mosquito. The flagella attack and fecundate the female forms, which 
penetrate into the muscular coat of the wall of the mosquito's stomach 
and there undergo development. After seven days these bodies, which 
protrude from the external wall of the mosquito's stomach, rupture, setting 
free great numbers of small spindle-shaped structures, which accumulate in 
the veneno-salivary glands of the mosquito. When such a mosquito bites 
again, these bodies are introduced. Each one of these is equivalent to 
one of the segments of the asexual cycle, and is ready to attack a new 
red blood-corpuscle and pursue a similar cycle. 

In this country there exist several varieties of anopheles, one of which, 
the anopheles quadrimaculatus, has been shown by Thayer and Wooley to 
act as an intermediate host for the parasite. It is not yet settled whether 
the anopheles can obtain the parasite from other sources than from man, 
although it seems probable that this is not the case. 

The facts which so far have been accumulated in Italy and in this 
country appear to show that the first cases in the spring and early 
summer are relapses. With the appearance of mosquitoes of the genus 
anopheles, which occurs probably in July or August, according to the 
part of the country, the spread of the disease begins, the fresh cases 
arising as a result of the transference of the infection from relapses. The 
disease gradually increases during the season in which the anopheles 
prevails, only to diminish again with the frosts and the disappearance of 
this type of mosquito. The ordinary house mosquitoes, which we see in 
most of our cities and towns, excepting in the very malarious districts, 
do not belong to the harmful class. They belong to the genus culex. 
The main differences between the culex and the anopheles are readily 
made out. In the first place, all the common forms of culex which we 
see have wings free from marking, beyond the ordinary veins. All three 
varieties of anopheles positively known in this country have spotted 
wings. The most important and simple distinction, however, is the 
manner in which these varieties of mosquitoes sit on the wall. The 
culex sits on the wall with its body parallel to the surface to which it is 
attached and the posterior pair of legs raised over its back. The anoph- 
eles, on the other hand, sits with its body sticking out from the wall at an 
angle of forty-five degrees or greater, with the posterior pair of legs, which 
are very long, resting against the wall or hanging down. When such a 
mosquito is sitting on the ceiling he looks often as if he were hanging 
from his proboscis. This distinction is readily made out by any layman. 
The anopheles and culex are represented in Plate XII., opposite page 874. 
A third point is the difference of the mouth parts. The ordinary house 
mosquito, the culex, has a single long proboscis, at the root of which are 
two little, short, stump-like processes, the palpi. In the anopheles these 
palpi are of a length almost equal to the proboscis, so that on superficial 
examination the mosquito looks as if he had three proboscides. 



SPECIFIC INFECTIOUS DISEASES. 483 

The frequency of malaria in infants and young children, which has 
been recognized for a good while, has been strikingly brought out by 
Koch's studies in Java. This frequency is in all probability in part due 
to the well-known fact that very young children are especially subject to 
mosquito-bites. A rather interesting point in connection with this is that 
Koch uses the presence or absence of malaria in infants as an index as 
to whether a district is or is not malarious. In adults it is always pos- 
sible that the disease may have been imported. Infants, however, have 
usually acquired the disease at home. The proportion of cases in infants 
appears to be greater than at any other age. When, then, the infants 
are free from malaria, or occasional cases occur among adults, it is prob- 
ably safe to say that the disease is imported. 

The germs of this parasite may be contained in the blood-plasma, or 
in the substance of the erythrocytes. The name plasmodium has been 
given to the germ found in the red blood-disks. According to Thompson, 
in acute paludism (malarial fever) the plasmodium is found in the form 
of amoeboid bodies, occupying a place in a certain number of the ery- 
throcytes or adhering to them. These bodies derive pigment (melanin) 
from the erythrocytes, and, after undergoing a certain degree of develop- 
ment, increase in size at the expense of the erythrocytes. They are found 
to contain this pigment in distinct granules and rods. They vary in size, 
and some are as large as the erythrocytes. They are at first colorless 
and transparent, and at the height of their development they undergo 
segmentation. This amoeboid form of the parasite is the one commonly 
found in what is designated as the tertian variety of malaria, and is the 
most common of all the known forms of the parasite of malaria. 

In addition to these amoeboid forms, crescentic shapes of the germ, ac- 
cording to the investigations of Laveran, are common in the blood of certain 
types of paludism, irregular forms of the disease, and malarial cachexia. 
Like the amoeboid forms, they are transparent and colorless, except for 
the pigment granules which they contain in their centres. They are larger 
than the amoeboid forms, are much more rare, are much less affected 
by the action of quinine, and are one form of the cestivo-autumnal 
variety. 

Councilman describes flagellate bodies as being most commonly found 
in blood which has been aspirated from the spleen ; and in acute cases of 
malaria they may sometimes appear in other situations. They exhibit 
from three to eight vibrating cilia. 

It is still a matter of dispute whether the plasmodium malariae is poly- 
morphous and thus may produce the different types of malaria, or 
whether there are certain distinctly separate organisms to which the name 
Plasmodium malarise is applied. 

There is no doubt that two distinct forms of parasites of malaria can 
be diagnosticated by the appearance of the plasmodium in the blood, and 
that these two forms can be separated clinically. 



484 PEDIATRICS. 

Golgi is the investigator who has most clearly shown that there is 
more than one parasite of malaria, while Laveran is the exponent of the 
polymorphous theory. 

The malarial parasite may be most simply and surely found by exami- 
nation of a fresh unstained specimen of blood. A small drop of fresh 
blood is placed on a glass slide and covered with a cover-glass, making a 
very thin layer, and examined with an oil-immersion lens. The slide 
and cover must be perfectly clean and dry. Dried and stained specimens 
are only to be used when an examination of fresh blood is impossible. 

There are definitely three varieties of the malarial parasite, tertian, 
quartan, and cestivo-autumnal. The sestivo-autumnal is usually associated 
with paroxysms occurring about forty-eight hours apart ; these paroxysms, 
however, being considerably longer than those in tertian or quartan fever. 
Very commonly, however, owing to multiplicity of groups of parasites, 
the fever is irregular, remittent, or continuous. The relation of these 
three varieties of malarial parasites to the periodicity of the disease is 
shown in Table 64, on page 486. 

The tertian parasite first appears in the red blood-corpuscles as small 
hyaline bodies with amoeboid movements. It increases in size and de- 
velops fine, dark, pigment granules, which are in constant motion, due to 
the amoeboid contractions of the protoplasm of the individual parasites. 
The red cells which contain them become slightly enlarged and gradually 
decolorized. Each parasite when fully grown nearly fills the red corpuscle. 
In the stage of segmentation, which occurs at the time of the paroxysm, 
fifteen or twenty segments appear, which invade fresh red corpuscles, and 
begin the cycle again as hyaline bodies. 

The quartan parasite resembles the tertian, but its amoeboid move- 
ments are slower, the pigment granules are coarser, darker, and less active, 
the full-grown organism is smaller, and the red cell in which the organism 
develops becomes somewhat shrunken about the parasite, and of a deeper, 
old-brass color. It segments into only five or ten parts. 

The wstivo-autumnal parasite is smaller than the others and contains 
less pigment. The corpuscles containing them become shrunken and 
brass-colored. About a month after the onset of the attack, character- 
istic crescentic or ovoid bodies appear, which have coarse pigment granules 
clumped in the centre. Flagellate forms of the tertian, quartan, and 
sestivo-autumnal parasites may appear. The segmentation of the organ- 
ism is always coincident with the paroxysms, and the interval between 
the paroxysms is characterized by a distinct and early stage of develop- 
ment of the parasites. 

The tertian form is the one which is by far the most common in this 
part of the country, and the one which is most influenced by the admin- 
istration of quinine, the other form, represented by the quartan, being 
peculiarly difficult to manage with quinine. In young infants the tertian 
form in its quotidian variety is met with most commonly. In older chil- 



SPECIFIC INFECTIOUS DISEASES. 485 

dren, in my experience, it is the pure tertian that is most common. It 
will be noticed, on examining the table on page 486, that the quartan 
form of paludism can never represent by its intervals and paroxysms the 
pure tertian form. 

Pathology. — There are no especial differences between the patho- 
logical lesions found in the malaria of children and those which occur in 
adults. According to Thayer, in acute cases of malarial fever, on exami- 
nation with the microscope, the cerebral capillaries are found to be 
crowded with malarial parasites. There is usually a marked granular de- 
generation of the endothelium of the vessels. 

The spleen is always enlarged, often only moderately. The parenchyma 
is cyanotic, of a slaty-gray color, and almost diffluent. The pulp of the 
spleen is found to contain enormous numbers of red blood-corpuscles, 
many of which contain parasites. Great numbers of white cells are also 
seen, some of them being necrotic. The capillaries are usually filled with 
red blood-corpuscles containing the plasmodia, while the splenic veins 
show relatively few, although they always contain large cells enclosing 
pigment or the remains of red blood-corpuscles. 

The liver is swollen and has usually a slaty-gray color. The capilla- 
ries are filled with leucocytes, which contain numerous pigmented bodies. 
Relatively few plasmodia are found in the blood-corpuscles in the vessels. 
Areas of disseminated necrosis similar to those in other acute infectious 
diseases have been described. 

The vessels of the kidneys contain relatively few organisms. The 
glomeruli may be considerably pigmented. There may be marked de- 
generation of the epithelium of the capsule, and at times changes in the 
parenchyma, especially areas of necrosis of the epithelium of the con- 
voluted tubules. The other viscera show no special characteristic changes, 
except, at times, that of melanosis. 

Symptoms. — The symptoms of malaria as the disease occurs in infants 
and young children are much more varied and far more uncertain than 
those which we are accustomed to meet with in adults. The prominent 
symptom of malaria being the paroxysm, earlier authors naturally classi- 
fied malaria according to the time when the paroxyms appeared, using 
the term quotidian when they occurred with intervals of twenty-four 
hours, tertian when they occurred with intervals of forty-eight hours, 
and quartan where they occurred with intervals of seventy-two hours. 
The term tertian is somewhat misleading unless we understand that it is 
a word derived from the Latin method of counting the day of the be- 
ginning of the febrile manifestation as the first day. The terms tertian 
and quartan, therefore, are simply used empirically to represent intervals 
of forty-eight and of seventy-two hours between the paroxysms. Again, 
the terms intermittent and remittent have been used commonly. The in- 
termittent form is characterized by entire absence of fever between the 
paroxysms. The remittent form is characterized by the presence of more 



486 



PEDIATRICS. 



or less fever of a continued type which does not cease between the 
paroxysms. These terms should not be used as classifications of distinct 
types of malaria, as the conditions which they represent may, according 
to chance, appear in any of the types, and are merely caused by a varia- 
tion in the behavior of the parasite. In general, in children there is a 
tendency in all types of malaria towards a deviation from the regular 
arrangement of parasites in groups, so that even in tertian and quartan 
fever the regularity of the manifestations appears to be not quite so 
striking as in adults. 

According to Koplik, in pure types of paludism, either tertian or 
quartan, one generation of the plasmodium will be found to predominate. 
In the cases of tertian variety, when the paroxysms are found to be of 
daily occurrence, several generations of parasites, each with a different 
cycle of development, will be found in the blood. The same observation 
will be found to be true when irregular types of fever with the tertian 
parasite are carefully examined, and also when the blood in quartan 
fevers is examined. If more than one generation of parasites exists in 
the blood in a tertian case, the fever may become quotidian, with daily 
paroxysms due to the ripening of distinct sets of parasites on different 
days, each set of parasites taking forty-eight hours to mature. In like 
manner, in cases of quartan fever, through the ripening of distinct sets of 
parasites on different days, different combinations occur, according to the 
number of sets of parasites. Thus, while in the form in which there is 
only one parasite the intervals between the paroxysms are seventy-two 
hours, in that in which there are two parasites there may be an interval 
between the paroxysms of only forty-eight hours, and when there are 
three parasites there may be an interval of only twenty-four hours, thus 
representing the quotidian chills described by Mannaberg. The following 
table explains the different types of paludism as they are now understood 
by the most recent investigators : 



TABLE 64. 

The Principal Combinations of Paroxysms caused by the Plasmodium Malarice. 



Tertian. 


Intervals. 


1st day. 


2d day. 


3d day. 


4th day. 


Pure tertian 

( One parasite. ) 
Double tertian 

(Two parasites. 

Quotidian. ) 


48 hours. 
24 hours. 


Paroxysm. 
Paroxysm. 


No paroxysm. 
Paroxysm. 


Paroxysm. 
Paroxysm. 


No paroxysm. 
Paroxysm. 


Quartan. 












Pure quartan 

(One parasite.) 
Double quartan 

(Two parasites.) 
Triple quartan 

(Three parasites. 
Quotidian. ) 


72 hours. 
48 hours. 
24 hours. 


Paroxysm. 
Paroxysm. 
Paroxysm. 


No paroxysm. 
Paroxysm. 
Paroxysm. 


No paroxysm. 

No paroxysm. 

Paroxysm. 


Paroxysm. 
Paroxysm. 
Paroxysm. 



SPECIFIC INFECTIOUS DISEASES. 487 

The table explains how the different intervals in the paroxysms are 
caused by the development of the parasite on different days. It will 
therefore be understood that it is according as the parasite happens to de- 
velop that we have a regular or an irregular periodicity. Thus, it may 
happen that we have two parasites, and these two parasites may develop 
on the same day, but at different hours. In this case, supposing that they 
are of the tertian type, two paroxysms may occur on the same day, fol- 
lowed by an interval of forty-eight hours from the time of the full de- 
velopment of each of the parasites until this development occurs again. 
In this way different broods of parasites may cause an almost infinite 
variety of symptoms. 

The younger the individual the more likely are the pronounced chills 
to be replaced by some other symptom, such as vomiting, delirium, and 
convulsions. The paroxysms come more frequently in children than in 
adults and in young children a condition of apathy and somnolence, some- 
times with fever, and sometimes accompanied by coldness of the extremi- 
ties and a collapsed condition, very commonly replaces the chill of the 
adult. These symptoms, representing the onset of the disease, may often 
disappear as the disease becomes established, and in their place we may 
meet with the symptoms of some other disease, such as bronchitis, torti- 
collis, and many other affections. The symptoms of these other diseases 
will often continue and be very intractable until quinine is given, when 
they will disappear, and thus we shall be led to believe that we have been 
dealing with one of the masked and misleading manifestations of the Plas- 
modium malariae, as illustrated by the case described on page 490. 

The susceptibility of the nervous and respiratory systems in young 
children to produce variations in the form and type of malaria is most 
misleading in regard to diagnosis, the symptoms referable to a particular 
organ often completely overshadowing the real disease, malaria, and pro- 
ducing an entirely new clinical picture. The symptoms often are so indefi- 
nite and the disease frequently comes on so insidiously that the physician 
does not see the case until it has made considerable progress and the diag- 
nosis is thus much obscured. 

In addition to the other symptoms, severe pain in the head and some- 
times in the epigastric region is met with. In the form in which the in- 
vasion is gradual, the prominent symptoms are anaemia, loss of appetite, 
and frontal headache of moderate type. The spleen in the majority of 
cases is" found to be enlarged. It is possible that in the cases in which 
no enlargement of the spleen is demonstrable it may nevertheless be 
present without our being able to detect such enlargement by percussion 
or palpation. Splenic and hepatic tenderness, pains in the back, extremi- 
ties, and neck, and general cutaneous hyperesthesia are occasionally 
observed. As the capsule of the spleen is less resistant in young chil- 
dren than in adults, the organ seems to enlarge more rapidly and also to 
subside more quickly in children. 



488 PEDIATRICS. 

The time and character of the onset of the disease and of its parox- 
ysms are very irregular, so much so, indeed, that it would not be prac- 
ticable to dwell upon the exact differences which occur from those in the 
adult. In general, the fever is relatively higher, and the sweating stage is 
apt to be absent. 

According to Holt's record of his cases in New York, the onset is acute 
with vomiting and prostration. The temperature is high, ranging from 
40° to 41° C. (104 to 106° F.). The respiration is feeble or harsh over 
the back of one or both lungs, sometimes with coarse moist rales, and 
usually a slight increase of vocal fremitus and slight dulness on percus- 
sion. These signs and symptoms may disappear in the course of a few 
hours with the fall in temperature, and may recur on the following days 
until quinine is administered. Bronchitis was found to be the most fre- 
quent of all the complications occurring in the course of malaria, and 
again and again proved to be intractable until its malarial origin was dis- 
covered. Certain of these acute cases appeared to be dependent upon 
pulmonary congestions analogous m their pathology to the congestions of 
the spleen and the liver. Pneumonia, both lobar and lobular, was occa- 
sionally found as a complication of malaria. Spasmodic asthma of ma- 
larial origin was seen in some cases. These attacks were accompanied 
frequently by marked splenic enlargement, and were promptly relieved 
by quinine. 

The condition of the intestinal tract varies as much as do the other 
symptoms. Sometimes constipation is present and sometimes diarrhoea, 
the latter being the more prominent the younger the child. 

Subacute and chronic forms of malaria occur in children as in adults, 
characterized by anaemia, splenic enlargement, a low grade of fever, and 
the presence of the parasites. 

Diagnosis. — Malaria as it occurs in early life is far more difficult to 
diagnosticate by its symptoms than when the disease runs the typical 
course usually seen in the adult. It is the most protean disease which 
we are called upon to deal with in young children, and it simulates so 
closely so many other conditions we are likely to meet with that we 
should always be on our guard, and allow the possibility of the existence 
of the plasmodium malariee in making a diagnosis in a doubtful case in 
which a periodicity is noticed in the symptoms. The only rational 
method of determining whether we are dealing with a case of malaria is 
by an examination of the blood, which at once settles the question if the 
Plasmodium is discovered. The parasite can usually be found in a patient 
who has had little or no quinine, if the blood is thoroughly examined 
during a paroxysm by a person who has had considerable experience. 
The absence of leucocytosis in malaria is an important aid in the exclu- 
sion of chills and fever dependent upon septic processes. 

Prognosis. — The prognosis of malaria in children is good, provided 
that the child is removed from the malarial district and is treated with 



SPECIFIC INFECTIOUS DISEASES. 489 

quinine. Relapses occur, even after long intervals of apparent immunity, 
and the disease can recur a number of times. When a child has been 
once attacked by the Plasmodium malarise it seems to be peculiarly vul- 
nerable to a second attack of the organism. 

Prophylaxis. — The value of mosquito-nets from a prophylactic stand- 
point is significant, and observations in malarious districts during the last 
year or two strongly support this idea. The fact that a patient with ma- 
larial fever in a malarious district is a source of danger to those about him 
is a very important one, the deduction being, of course, that one should 
insist upon such an individual sleeping under a mosquito-net. The im- 
portance also of early and thorough treatment of all cases of malaria, par- 
ticularly relapses in the early malarial season, is evident. In some regions 
destruction of the mosquito larvae may accomplish a great deal, although 
much further research is necessary to determine the places in which these 
particular varieties of mosquito breed. 

Treatment. — Quinine is the only drug which can be relied upon to 
eradicate the Plasmodium malariae from the blood, and is therefore the 
only medicine for this purpose which I shall mention. 

The sulphate or hydrochlorate of quinine may be given to an infant 
under six months in doses of 0.03 gramme (J grain) ; at one year the dose 
may be 0.06 gramme (1 grain) ; at two years it may be 0.12 gramme (2 
grains), and it can be increased up to 0.3 or 0.36 gramme (5 to 6 grains) at 
five and six years. There is little danger of giving too large doses of quinine 
to children, as they tolerate the drug very well. The bisulphate of qui- 
nine is much more soluble than the sulphate, and for this reason is pre- 
ferred by many physicians. The hydrochlorate of quinine is very much 
more soluble in water than either of the sulphates, requiring only thirty- 
five times its own weight of water as compared to eight hundred times its 
weight when the sulphate of quinine is used. The addition of hydrochloric 
or sulphuric acid renders the hydrochlorate of quinine soluble in less than 
its own weight of water, and the sulphate in ten parts of its weight of 
water. The dose of the hydrochlorate of quinine is the same as that of 
the sulphate. It is sometimes desirable in very severe cases to get the 
organism promptly under the influence of quinine. For this purpose the 
very soluble double hydrochlorate of quinine and urea may be given sub- 
cutaneously in doses of 0.06 to 0.3 gramme (1 to 5 grains), according to the 
age of the child. The latest investigations have shown that the Plasmo- 
dium is most sensitive to the action of quinine when it is corpuscular. 
Hence the quinine should be given shortly before the paroxysm. 

It has been noticed that the administration of quinine tends to inter- 
fere with the regularity of the time of the paroxysm, and in this way other 
variations may occur. If the paroxysm comes earlier in the day than 
usual, the disease is apt to be of a severe type and to be growing worse, 
while if the interval is lengthened and the attack is found to come 
at a later hour in the day than usual, it is a sign that the disease is 



490 PEDIATRICS. 

amenable to treatment, is of a benign character, and is tending towards 
recovery. 

The manner of administering quinine is rendered somewhat difficult 
on account of the bitter taste of the drug and its insolubility in water. 
In very young infants, and in fact in the first six or eight months of life, it 
is well to try the effect of quinine in suppositories. In older infants and 
in children it can usually be successfully concealed in a small amount of 
chocolate cream. Quinine should never be given in pill form, but always 
in capsules or in solution to make sure that it is absorbed. 

The time for the administration of the quinine should be regulated 
as carefully as in the adult. The dose should be given three or four 
times in the twenty-four hours, and one of the doses should be given 
from four to six hours before the paroxysm, so that the blood-serum 
shall be charged with the quinine at the time when the young and more 
sensitive parasites have just broken out from the blood-corpuscle. It is 
well to continue the treatment with quinine for some weeks after the 
paroxysms have ceased, as the symptoms often return if the quinine is 
omitted at once. 

The anaemia which always accompanies the disease to a pronounced 
degree should be treated with arsenite of potash, or with some mild form 
of iron, such as the saccharated carbonate or the tartrate of iron and pot- 
ash, as described under Secondary Anaemia, on page 896. 

The following prescriptions, varied to suit the individual, are what I 
am in the habit of using in cases of malaria : 

Prescription 74. 

For an Infant under Six Months. 
Metric. Apothecary. 

Gramma. 

R Quininae hydrochloratis 

Olei theobromae 11 

M. M 

Ft. suppos. no. 12. Ft. suppos. no. 12 

S. — One suppository to be used every 6 hours. 



36 R Quininae hydrochloratis gr. vi 

25 Olei theobromae giii. 



Prescription 75. 

For Older Children. 
Metric. Apothecary. 

Gramma. 

00 R Quininae hydrochloratis ^iss ; 

Acidi hydrochlorici dil q.s. 

00 Aquae destillatae ^ ii 



R Quininae hydrochloratis 6 

Acidi hydrochlorici dil q.s. 

Aquae destillatae 60 

M. M. 

Sig. — Teaspoonful once in 6 hours 



The following case of an infant, a few days old, was probably one of 
malaria, but no examination of the blood was made : 

The infant's mother had malaria during her pregnancy, and some of the manifes- 
tations of the disease appeared ten days before the birth of the infant. The infant 



SPECIFIC INFECTIOUS DISEASES. 



491 



from the earliest days of its life showed symptoms of severe digestive disturbance, 
characterized by vomiting and diarrhoea, and far beyond what could be accounted for 
by the lack of equilibrium of the function of the mother's mammary gland. A care- 
ful physical examination failed to detect anything abnormal in its thorax or abdomen. 
Observations of the temperature in this case, taken both in the axilla and in the rec- 
tum, showed that it was of an irregular type, varying from 37.2° to 38.3° C. (99 c 
to 101° F.) rectal, and that at times in the latter part of the day it rose to 39.4° 
to 40° C. (103° to 104° F.) axillary. Every day at about 1 a.m. there was a parox- 
ysm, represented by cyanosis, coldness of the entire skin, both of the body and of the 
extremities, collapse, and somnolence. These attacks, beginning at the seventh day of 
life, lasted until the twelfth day, when quinine in 0.03 gramme (J grain) doses, given 
in suppositories and administered every two hours for seven doses, at once and com- 
pletely checked the paroxysms. From this time the attacks entirely disappeared, the 
food was well digested, and the infant seemed perfectly well. 

The following cases occurred in my service at the Children's Hospital : 

A boy, nine years old, was admitted on the 13th day of February. He lived 
in a malarial district until one year ago. He had had a slight cough, anorexia, malaise, 
night-sweats, and rapid loss of flesh for several weeks. The movements of the bowels 
were rather irregular. According to his mother's report, he had never before had 
any symptoms of malaria. The child was pale and emaciated. On physical exami- 
nation there was resonance over both lungs, and on auscultation a few moist rales and 
an occasional sibilant rale were heard. The area of cardiac dulness and the sounds 

Fig. 11-5. 





Boy, 9 years old. Enlarged spleen. Plasmodium malariae found in the blood. 



of the heart were normal. The liver was not enlarged, but the spleen was very 
much increased in size, the limits of its enlargement are marked in black in Fig. 
115. The upper border rose as high as the sixth rib in the axillary line, and extended 
down into the left inguinal region. The urine was normal. 

The case represented the tertian form of malaria. The child had never had a chill 



492 



PEDIATRICS. 



until 3 p.m. two days after entering the hospital. The chill lasted about one hour, and 
was followed by sweating. A paroxysm of some kind, represented either by a chill 
or by a decided rise in temperature with chilly sensations, occurred on the 17th, 19th, 
21st, 23d, 25th, 27th, and 29th of February, March 2, and March 4, and on March 6 
there was a decided rigor at 4 p.m. On March 8 the paroxysm occurred in the morn- 
ing at half-past twelve. On the morning of March 10 the paroxysm occurred at about 
half-past eleven, and was followed by marked sweating. Between the paroxysms the 
boy appeared to be very well. He had a fair appetite, and gradually gained in weight 
and strength. 

On March 10, immediately after the paroxysm, the blood showed the Plasmodium 
malarias. The appearance of the blood in this case is shown on Plate XII., facing page 
£74. The count gave the following results : 

Erythrocytes 2, 935,000 

Haemoglobin 36 per cent. 

Leucocytes 25, 500 

A large number of the erythrocytes contained the plasmodium malarias. The 
leuoocytosis Dointed towards some complication, but none was at any time discovered. 



















CHART 


16. 




















Days of Disease. 




F 

107° 
106° 
105° 
104° 
103° 
T02° 
101° 
100° 


23 


24 


2J 


26 


27 


28 > 


i 30 


31 


32 


33 


34 


35 


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37 


38 


39 


40 


41 


42 


43 


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96° 
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110 
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80 
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Pure tertian form of malaria. {C means cnill.1 



The chills continued on March 12, 14, and 16. On March 17, 0.36 gramme (6 grains) 
of quinine was given six hours before the paroxysm was expected to return. On 



SPECIFIC INFECTIOUS DISEASES. 



493 



March 18 there was no paroxysm. The quinine was given regularly three or four 
times a day for several days, and the paroxysms did not return. 

Chart 16 represents the temperature and pulse of this case. The days representing 
the disease were necessarily only approximate for the first twenty-two days, and the 
child was supposed to have entered the hospital on the twenty-third day of the disease. 
The first chill occurred on the twenty-fifth day, as is shown in the chart. 

Subsequently the quinine was omitted, the chills did not return, the spleen re- 
covered its normal size, the anaemia disappeared, and the child grew fat, and left the 
hospital in good condition. 

The second case was that of a girl, nine years old, who entered the hospital also 
on the 13th of the month. She represented, in contradistinction to the tertian form 
of malaria seen in the boy, a case of the double tertian (quotidian) form. She had 
been living in a malarial district, but had never had any previous symptoms of malaria, 

Pig. 116. 




Girl, 9 years old. Enlarged spleen. Plasmodium malariae found in the blood. 



although a sister living in the same house had been affected by the disease. Four 
weeks before entering the hospital she had an attack of vomiting, nausea, and head- 
ache, without any apparent cause. These symptoms recurred at intervals for two weeks, 
when she began to have chills occurring every day at about 5 p.m. These chills con- 
tinued, with the exception of four days, until her entrance to the hospital. 

She was fairly developed and was very anaemic. On physical examination moist 
rales were heard over the bases of the lungs behind. The heart showed no increase in 



494 



PEDIATRICS. 



the area of dulness, but there was a soft systolic murmur over the whole praecordia. 
This murmur was most intense over the pulmonic area. The pulmonic second sound 
was not accentuated. The murmur was heard in the jugular veins. An examination 
of the abdomen showed it to be soft and tympanitic. The liver was enlarged, so that it 
extended 2.5 cm. (1 inch) below the border of the ribs. The edge of the spleen was 
plainly felt, and the percussion dulness extended downward to the level of the umbili- 
cus and upward as far as the sixth rib, and is designated by a black line, as seen in 
Fig. 116. The urine was high-colored and had a specific gravity of 1025, but was 
otherwise normal. 

CHART 17. 



days ofDisease^ 




07° - 

m° - 

105° - 
104° - 
103° - 
102° - 
I0I 3 - 
KX>° - 

& j 
98° - 
97° " 
96° - 
95° = 


8 29 


30 31 


32 33 


34 


35 


36 


37| 38 


39 


40 


41 


42 


43 


44 


45 


46|47 


48 




416° 
41. 1" 

40.5° 
40.0° 
39 4° 
388» 
38.3° 
37.7° 
37.2" 

36 l e 
355°- 
35 0" 


E M E 


H EM E 


M EM E 


M E 


M E 


SI E 


M Epd E 


M E 


ME 


ME 


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= 



Double tertian form of malaria (quotidian), (c, chills.) 



On the day of entering the hospital (the 13th) the child's temperature was raised, 
but there was no chill. On the following day, the 14th, there was a chill at 4 p.m. 
On the 15th there was a marked chill, with a considerable rise of temperature. 

Immediately after the paroxysm an examination of the blood was made with the 
following result : 

Erythrocytes 3,396,250 

Haemoglobin 30 per cent. 

Leucocytes 5,000 

Plasmodium malarite present. 



It was noted that the splenic enlargement was greatest during the chill. 
On the 16th there was a chill, and the temperature rose to 40.6° C. (105. 2 ( 
the maximum attained during the course of the disease. 



F-), 



SPECIFIC INFECTIOUS DISEASES. 495 

On the 17th and 18th the chills recurred. 

On the 18th 0.36 gramme (6 grains) of sulphate of quinine was given at 12.30 p.m. 

On the 19th there was no rise in the temperature, and no quinine was given. 

On the 20th and 21st there were no chills, but a slight rise of temperature, and 
12 gramme (2 grains) of quinine was given four times daily. 

On the 22d she had a chill, and the temperature was 40.50 C. (105° F.). 

For the next sixteen days 0.6 gramme (10 grains) of quinine was given in the 
course of each twenty-four hours, the spleen gradually growing smaller. As the tem- 
perature was still irregular, the quinine was then increased to 0.72 gramme (12 grains). 
The temperature remained normal for three days, and then was again slightly raised 
and irregular. Two weeks later the quinine was omitted. 

The following are the records of two infants who apparently were 
suffering from the effects of the plasmodium malariae, although no exam- 
ination of their blood was made : 

The first one was one year and ten months old. The infant had lived in a mala- 
rial district until within a few weeks of the time when I saw him. 

The history which was given to me by his mother was that for several weeks he 
had had attacks represented by a chill or chilly sensations, occurring every day about 
noon. These attacks had recurred for about a week or ten days before I saw him. In 
connection with the chill and the fever the infant usually became unconscious, and its 
feet and hands were cold and clammy. 

0.06 gramme (1 grain) of quinine was given to the infant on the 29th of April,, 
and on the following day none of the usual manifestations occurred at noon, but at 
about 4.30 p.m. he had a chill and a slight rise of temperature, but was not unconscious. 
0.03 gramme (£ gram) of quinine was then given, and on the following day, April 
30, 0.06 gramme (1 grain) of quinine at 10.30 a.m. On this day there was a decided 
chill, and the rectal temperature rose to 40.5° C. (105° F.). During the attack the 
child breathed rapidly ; its feet, hands, and nose became cold, and it was practically 
unconscious for some minutes until its circulation was restored by injections of warm 
water and brandy. 0.03 gramme (£ grain) of quinine was then given three times 
during the twenty-four hours. On the following day none of these abnormal symptoms- 
occurred. On the next day 0.03 gramme {\ grain) of quinine was given in the morn- 
ing and again at night, and this dose was continued for a few days. From this time 
the symptoms of malaria entirely disappeared, the infant grew less and less emaciated,, 
became stronger, had a good appetite, and continued to thrive. No enlargement of the; 
spleen was detected in this case. 

The next infant was nineteen months old, and was brought from a decidedly mala- 
rial district. 

It had previously been well until three weeks before it was brought to be treated for 
the following symptoms. At the time when its bath was given to it, which was be- 
tween 11 and 12 in the morning, it had symptoms characterized by drowsiness and 
cyanosis, and it would fall asleep, and after about half an hour would wake up bright 
and well. These attacks, although short in duration, were very alarming and apparently- 
serious, as, although the infant did not have any pain or convulsions, it could not be 
roused while in the attacks, and became so blue and cold that it was feared that it 
might die in one of them. At the time of the attacks the rectal temperature varied 
somewhat, but was usually about 38.3° C. (101° F.). 

The treatment of this case was with sulphate of quinine, sometimes given by the 
mouth and sometimes by means of rectal suppositories. After the administration of 
the quinine for four or five days the attacks entirely ceased and did not return. The 
infant from that time continued to thrive. 



496 PEDIATRICS. 

TETANUS NEONATORUM. 

Tetanus neonatorum is an acute infectious disease, usually occurring 
in infants from the third to the twelfth day of life, and is almost always 
fatal in two or three weeks. 

Etiology. — The cause of the disease is the same as that of tetanus in 
the adult, — that is, the bacillus of tetanus, — and the organism is supposed 
usually to gain its entrance at the umbilicus. This disease is epidemic in 
tropical climates, but as we see it is usually of a sporadic nature. 

Symptoms. — After considerable restlessness and muscular twitching, 
lasting for some hours, the infant assumes a very characteristic appear- 
ance. There is extreme rigidity of the legs and body. This rigidity 
sometimes takes the form of opisthotonos and trismus (rigidity of the in- 
ferior maxilla). The eyes are almost closed, but the infant is sleepless. 
The trunk and limbs are so stiff that the infant remains in whatever 
position it is placed. It is unable to nurse, and has a high temperature, 
occasionally reaching 40° C. (104° F.), and a pulse of 150 or 160. At 
times it will have slight convulsive attacks. 

Prognosis. — It is extremely fatal. When recovery takes place the 
improvement is very gradual, the temperature and pulse decreasing and 
the rigidity of the muscles passing away very slowly, with at times a re- 
currence of the symptoms. 

Treatment. — The treatment of this disease has thus far been very 
unsatisfactory. The possibility of successfully treating these cases with 
the antitoxin of tetanus must be considered ; but the results so far obtained 
have not been brilliant, and it is doubtful if the cases so treated show a 
lower mortality than those in whom the treatment has been only symp- 
tomatic. 

The form of treatment which appears to me most rational is to place 
the child during the continuation of the tonic spasm in a warm bath and 
to give it 0.06 gramme (1 grain) of hydrate of chloral every hour until the 
effects of the drug are shown by the lessening of the muscular rigidity 
and by a disposition to sleep. In addition to this treatment, small quan- 
tities of milk, 15 c.c. (about J ounce), should be giv*en to the infant by 
means of a dropper every hour, and to each feeding three minims of 
brandy or some other stimulant should be added. Under this treatment a 
certain number of cases have been known to live. 

The following case may be considered as one of the milder forms of 
tetanus neonatorum : 

An infant, said to have been healthy at birth and to have nursed without difficulty 
during the first week of its life, refused to nurse, apparently from inability to open its 
jaws. It sometimes cried, but feebly. There were no convulsions, no vomiting, and 
no rigidity in any other part of the body. The temperature was not taken. On physi- 
cal examination it was found that, although the infant could swallow, the jaw could 
not be opened wider than 1.2 cm. (£ inch). On forcing the finger between the jaws, 



SPECIFIC INFECTIOUS DISEASES. 497 

nothing abnormal was discovered in the mouth or pharynx. The respiration was 
regular, but rather shallow, and there was no evidence of injury. Nothing else ab- 
normal was discovered. 

It was given 0.06 gramme (1 grain) of hydrate of chloral three or four times in 
the twenty-four hours, and two days later showed marked improvement, with the excep- 
tion of still being unable to open the jaws widely, nothing else abnormal was discovered. 
The rectal temperature subsequently became normal, and it finally recovered. 

ERYSIPELAS. 

Erysipelas is an infectious disease, caused by the streptococcus pyo- 
genes. The term is. applied to an inflammation of the skin, subcutaneous 
tissue, and mucous membranes which has the following characteristics. 
It especially involves the lymph-spaces and lymph-vessels. It has a 
tendency to spread, and is attended by unusual swelling of the sub- 
cutaneous tissue and an intense red color of the skin or the mucous 
membrane. In addition to these local appearances it is accompanied by 
constitutional symptoms, which are mostly the result of a heightened 
temperature. 

The disease runs an acute course, is contagious, enters the individual 
through some abrasion of the skin or mucous membrane, and -is self- 
limited. 

Pathology. — The tissues may be swollen by an accumulation of 
serous fluid, which may be nearly transparent, or turbid from admixture 
with pus-cells. The pus-cells may infiltrate the tissues either sparsely or 
in dense masses. Sometimes vesicles are found on the surface, or there 
may be crusts. At times more or less of the affected region is filled with 
abscesses or becomes gangrenous. In other cases, aside from the local 
lesions petechiae are found in the serous membranes, and swelling of the 
spleen and parenchymatous degeneration of the kidneys and liver. When 
the mucous membranes are affected they show the same appearances as 
the lesions of the skin, except so far as these are modified by the different 
structure of the tissue. The disease may attack the larynx and upper 
air-passages and result in oedema. Pneumonia may occur as a compli- 
cation. 

Although the different organs, such as the spleen, kidney, heart, and 
liver, at times show pathological changes, nothing characteristic of erysip- 
elas has been found in these organs, but only such changes as may occur 
from a continued high temperature or as the result of sepsis. 

Symptoms. — Erysipelas may be divided into two forms, — migrans, ex- 
tending from surface to surface, and ambulans, occurring in different parts 
of the skin. It may also be acute or chronic. In erysipelas migrans, 
which is the most common form, the whole surface of the body may be 
attacked. It is very prone to return, passing over the same surfaces of 
the skin again. The face and head are not so commonly attacked in 
infants as in adults, and the disease seldom spreads from another part of 
the body to the head. When it does attack the head, it is apt to be fatal 

32 



498 PEDIATRICS. 

from a secondary purulent meningitis. It at times causes great swelling and 
tension, and may go on to gangrene in certain localities, such as the scrotum. 

The stage of the incubation of erysipelas lasts, according to Osier, 
from three to seven days. 

After the first year erysipelas so closely resembles the disease as it 
occurs in adults that we need not consider it in this later period of life. 
It is a somewhat frequent disease in infants up to six months of age. 
It then becomes less frequent up to the first year, and after that and in 
childhood is rather rare. I shall, therefore, speak of erysipelas as it 
affects infants only. 

The erysipelas of infancy may be divided into erysipelas of the new- 
born and erysipelas of sucklings. 

Erysipelas of the New-Born. — When erysipelas occurs before the 
end of the third week the infant seldom lives, and indeed it is a most 
dangerous disease up to the end of the third or fourth month. Erysipe- 
las of the new-born is apt to occur during an epidemic of puerperal 
fever. If the mother has any septic symptoms, the infant should be im- 
mediately taken away from her. I have seen a case where the mother 
had puerperal peritonitis following her delivery, and the infant, who was 
allowed to nurse her, was attacked by erysipelas. 

In many cases occurring in the early days of life the disease starts on 
the genitals, and may be complicated by other diseases, such as empyema 
and especially pneumonia. During the course of the disease the fonta- 
nelle sinks, the spleen is enlarged, convulsions may occur, and peritonitis 
accompanied by vomiting may arise as a complication. The disease is 
liable to invade the tissues at any point of abrasion, whether from the 
forceps or from vaccination, or at the point of separation of the um- 
bilical cord. The latter is the most common locality for the infection to 
take place. From this point the infection may extend and produce a. 
gangrenous condition of the stomach or abdomen. 

Although the temperature in the early hours or even days of the 
disease may not be raised, yet, as a rule, fever soon appears, the temper- 
ature varying from 39° to 41° C. (102.2° to 105.8° F.). Reddening 
and swelling, not of a high grade at first, appear on the part affected. 
The infants show symptoms of a general sepsis. Vomiting frequently 
occurs, followed by collapse and, almost without exception, by death. 

Treatment. — The treatment of this severe form of erysipelas is by 
stimulants and a substitute food adapted to the infant's digestion. 

Erysipelas of Sucklings. — When the disease occurs in the early 
months of life, its beginning is usually accompanied by cold extremities 
and collapse. The temperature is raised, and the higher its degree the 
graver the prognosis. The temperature curve, as a rule, is intermittent 
with considerable morning and evening variations, except in the more 
severe forms, in which there is continued high fever ; in the latter cases 
icterus is apt to develop. 



SPECIFIC INFECTIOUS DISEASES. 499 

The efflorescence, although very similar to that which is seen in the 
adult, differs somewhat on account of the more delicate structure of the 
infant's skin. It begins as a faint erythema, which spreads rapidly and 
as quickly disappears, sometimes within twenty-four hours, and twenty- 
four hours later desquamation may occur. The light color of the efflo- 
rescence soon becomes darker and more intense, and is accompanied by 
swelling, heat, and tension of the subcutaneous tissue. After the efflo- 
rescence has continued for a certain number of days, depending upon 
the amount of the surface of the skin involved, the extension of the 
disease ceases and the temperature falls. The redness gradually disap- 
pears, and the skin becomes covered with yellowish-brown crusts. 
Finally, desquamation takes place, and the skin recovers its normal 
appearance, the disease extending over a variable period according to 
the greater or less extent of the surfaces invaded. 

Although the disease when involving large surfaces is dangerous, yet 
cases in the later months of infancy recover even when the attack has 
been a severe one. An instance of this kind came to my notice in which 
an infant ten months old was attacked with erysipelas, the point of infec- 
tion being the right labium. 

In this case the whole vulva shortly became very tender and the disease extended 
to the pubes and abdomen. It invaded every part of the body and extremities and 
the head and neck. The eyelids and lips were the last points of attack. Even the 
palms of the hands and soles of the feet were affected. From the time that it ap- 
peared at one part of the body until the skin of that part assumed its normal color 
again was four days. When the erysipelatous inflammation extended to the feet there 
was marked oedema. The duration of the attack from its first appearance at the vulva 
to its disappearance at the eyes and mouth was about fifteen days. The infant was 
treated with small doses of iron and quinine, and recovered entirely. 

Treatment. — No treatment of which I know is of any avail in cutting 
short the disease in early life. According to Dr. J. C. White, the exten- 
sion of the efflorescence in adults can be controlled and the attack 
frequently aborted by the continuous application of the following wash : 

Prescription 76. 
Metric. Apothecary. 

Gramma. 

R Acidi carbolici (xtals) 3 

Alcohol, 

Aqua? aa 240 



75 R Acidi carbolici (xtals) gi ; 

Alcohol, 

Aquae aa ^ viii. 



I 



Where large surfaces are affected, the application of cold compresses 
tends to depress the vitality of the infant, which it is so important to sus- 
tain. During the height of the disease the infant's strength should be 
supported by stimulants and by the frequent administration of a food 
adjusted to its digestion. 

Plate X., facing page 610, represents the typical efflorescence of the 
erysipelas of sucklings as it occurred in a female infant six months old. 



500 



PEDIATRICS. 



It had always been healthy, and was nursed until within three weeks of the time 
of entrance, when it was weaned from the mother and nursed by another woman. It 
was of normal weight and general development. 

The first symptoms which were noticed were vomiting and a temperature of 39.5° 
C. (103. 5°F.) in the axilla. It seemed weak and languid, looked badly, and refused 
to take the breast. An examination of the breast-milk showed a peculiar green color, 
which not only appeared in the milk when drawn from the breast, but also, when the 
analysis was made, appeared in the curd resulting from the precipitation of the pro- 
teids. The analysis of the milk was as follows. The nature of the micro-organism 
which produced the green color was not determined. 

Fat 4.56 

Sugar : 6.36 

Proteids 3.46 

Mineral matter 0. 13 

Later in the day a pink efflorescence appeared just above the pubes, and there 
was found to be considerable irritation in the neighborhood of the vagina. The red- 
ness extended from the vagina to the suprapubic efflorescence. The efflorescence was 

CHART 18. 

















Daj/s 


of Disease 
















F 

107° 

106° 
105° 
104° 
103° 
102° 
\0i° 
100°' 
99° 

NORMT. 
TEM'P. 

98° 
97° 
96° 
95° 


5 


6 


7 


8 


9 


10 


1! 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 


22 


23 


24 


25 


tf E 


M E 


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SI E 


M E 


VI E 


M E 


M K 


M E 


M E 


M E 


M E 


M E 


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M E 


M E 


M E 


M E 


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416* 
41.1° 

40.5° 
40.0° 
39.4° 
38.8° 
38.33 
37.7° 

37.2° 

37.0° 
36 6° 

36. 1° 

35.5? 

35.0° 



Erysipelas of legs. Female, 6 months old. 

of an erythematous type. On the following day it spread to the left thigh, and 
then to the left lower leg. The temperature continued to be raised, and the infant 
refused to nurse. Small quantities of a substitute food with the following percentages, 
which had to be varied from day to day, were given to it : 

Prescription 77. 

Fat 2.50 

Sugar 6.00 

Proteids 1.50 



There were no convulsions or other symptoms, but the infant lost somewhat in 
strength and weight and its face looked pinched. 



SPECIFIC INFECTIOUS DISEASES. 501 

The efflorescence on the left leg began to fade on the ninth day of the disease, 
and on the tenth day the temperature became almost normal. On the following day, 
however, it again rose, and a fresh efflorescence began to appear on the right thigh 
continuous with the efflorescence of the suprapubic region. This efflorescence ex- 
tended down the right leg to the ankle. 

On the twelfth day the skin of the left leg was in some places almost normal, in 
others was covered by thin brownish-yellow crusts. The suprapubic region and the 
right leg as far as the ankle were covered with a bright red efflorescence sharply 
bounded by normal skin below, just above the ankle, as though it were a stocking. 
The whole leg was swollen, was hotter to the touch than the sound skin, and presented 
a somewhat raised, glistening appearance. 

No external applications and no drugs were employed in this case. The milk 
was carefully modified, and small doses of brandy were given. 

A few days later the temperature became normal, the efflorescence began to fade, 
desquamation subsequently took place, and the skin finally recovered its normal ap- 
pearance. The infant gradually regained its strength, became perfectly well, and had 
no return of the disease. 

Chart 18 shows the temperature during the course of the erysipelas in this case. 

This form of erysipelas may become chronic, and this is more apt to 
occur in children than in infants. It is also most common in children 
who are in a debilitated condition, and may occur at intervals of three or 
four years. It is in older children frequently connected with chronic in- 
flammations of the Schneiderian membrane, and in these cases is peculiarly 
intractable to treatment. 

AMGEBIC ILE0-C0LITIS. 

(Synonyms. — Tropical or Endemic Dysentery). — Etiology. — The 
later researches of Flexner and others seem to point towards the fact that 
there are at least two forms of tropical dysentery. One form, the bacil- 
lary, is as yet subjudice, while the other, the amoebic, has been established 
as a specific infectious disease, caused by a well-recognized organism called 
the amoeba coli. The amoeba coli is an animal micro-parasite belonging 
to the group of protozoa. The disease is of rare occurrence in children, 
and is very infrequent in northern climates. It is seen for the most part in 
the tropics. A common source of infection is by means of drinking-water. 

Pathology. — Amoebic ileo-colitis has its own definite anatomical 
lesions, which consist of round, oval, or irregular ulcers, the edges of 
which are infiltrated and undermined, so that individual ulcers may be 
connected by submucous sinuses. Amoebae are found in the lesions and in 
the intestinal discharges. The large intestine is more commonly the seat 
of the disease, especially the caecum, hepatic and sigmoid flexures, and 
the rectum. 

The disease may advance- by progressive infiltration of the connective 
tissue of the intestines, giving rise to large sloughs. In the same manner 
the liver may become infected, producing lesions in the nature either of 
local necroses of the parenchyma or of abscesses, which may be single or 
multiple. Cultures taken from the abscesses are generally sterile, but the 



502 PEDIATRICS. 

amoebae may be in the walls of the abscesses. Similar abscesses found 
within the lungs are a result of direct extension from the liver through 
the diaphragm. 

Symptoms. — The disease is usually acute in its onset, but sometimes it 
may be gradual. The duration may be two or three months. The diar- 
rhoea at first may be transient and trifling in character, but in the severe 
gangrenous forms is abrupt and intense. The course of the disease is 
irregular. The diarrhoea is characterized by exacerbations and remissions, 
and progressive loss of flesh and strength. The fever is moderate, and in 
some cases is absent. Nausea, vomiting, abdominal pain, and tenderness 
are usually only present in the severer forms. The stools present a 
variety of appearances ; they are generally watery and mixed with mucus, 
and sometimes with blood, but in the intermissions and convalescence are 
formed. The amoebae, with their characteristic movements, may be found 
when the stools are fluid, but rarely if they are formed. 

Diagnosis. — -There are no especial symptoms by which to distinguish 
this form of ileo-colitis from other forms of ileo- colitis, which are de- 
scribed on page 820, and the only positive proof of the existence of the 
disease is the presence of the amoebae in the discharges. 

Prognosis. — The prognosis is very unfavorable. Recovery is slow. 
The anaemia and weakness delay convalescence, and relapses are com- 
mon. An involvement of the liver generally leads to a fatal issue. 

Treatment. — The treatment which has been followed by the most 
favorable results is, in addition to frequent and thorough irrigation of the 
intestine, injections of solutions of sulphate of quinine (1 to 5000). This 
treatment, however, affects only the amoebae which are in the intestine, 
and not those which are embedded in the tissues. The anaemia should 
be treated as described on page 896. The diet should be carefully regu- 
lated and adapted to the age of the individual. Milk, beef-juice, egg 
albumin, and broths should constitute the principal food, and in the con- 
valescence it is necessary to exercise especial care in the management of 
the digestion. 

CHOLERA INFANTUM. 

Cholera infantum is an infectious disease caused by a specific organ- 
ism not yet discovered, and characterized by acute gastro-enteric disturb- 
ance with intense choleriform symptoms. The term cholera infantum 
should be exclusively restricted to this class of cases, and should not be 
used to designate the many acute and serious attacks of vomiting and 
diarrhoea which are so often designated cholera infantum. It is a rare 
disease. 

Etiology. — The organism which has been found most commonly in 
cholera infantum is in the proteus group. The disease occurs in the first 
two years of life, and in its development is probably closely associated 
with the food, for it has been noticed that infants who are fed exclusively 



SPECIFIC INFECTIOUS DISEASES. 503 

on pure and sterile foods, such as breast-milk, are not liable to be attacked 
by it. It is also significant that the disease occurs only in hot weather. 

Pathology. — The pathology of cholera infantum has not yet been 
satisfactorily determined, but it seems to be a non-inflammatory disturb- 
ance of the whole gastro-enteric tract, without any gross lesion beyond a 
desquamative catarrh, and sometimes hypersemia of the mucous membrane. 

Symptoms. — The onset of cholera infantum may be sudden, but, as a 
rule, it is preceded by some form of gastro-enteric disturbance, which, by 
causing an irritation of the mucous membrane, renders the infant vul- 
nerable. When, however, the disease has once gained a foothold, the 
development of the symptoms is very rapid. 

After a variable but generally short period of restlessness and ap- 
parent abdominal discomfort, the infant begins to vomit. The vomiting 
is either accompanied or quickly followed by profuse diarrhoea. After the 
stomach and intestine have been emptied of the food which may happen 
to be in them at the time of the onset, the vomitus and the diarrhceal 
discharges are chiefly serous ; and it is this watery consistency of the 
discharges which especially characterizes the disease. As a rule, the dis- 
charges are odorless, and consist of serum mixed with epithelial cells and 
many bacteria. Although the disease is more likely to attack weak and 
debilitated infants, yet it often attacks those who are healthy and robust. 
It may run its course to a fatal issue in from twenty-four to forty-eight 
hours. The extremities soon become cold, the skin is pallid or even 
cyanotic, and the face pinched. The abdomen may be a little distended, 
but is soft, and soon becomes rather retracted. The pulse is rapid and 
difficult to count. The respirations are somewhat quick and superficial. 
The temperature of the entire surface of the body is low, but the deep 
rectal temperature is high, 39.4°, 40°, or 40.5° C. (103°, 104°, or 105° 
F.). The thirst is great and is a very prominent symptom. The fonta- 
nelle very soon becomes depressed. The urine is very scanty and 
sometimes suppressed. It is concentrated, highly acid, almost always 
contains albumin, and often casts and blood. Nervous symptoms, such as 
twitching of the arms and great restlessness, are present. Rapid emaci- 
ation takes place, and all the symptoms increase in severity. At first the 
infant whimpers, but soon it becomes listless, falls into a stupor, or may 
have convulsions. The infant may die in this stage, which closely re- 
sembles the algid stage of cholera Asiatica. The disease appears to be 
self-limited, and if the infant survives the first two or three days a crisis 
comes, the skin becomes less cool and of a better color, the vomiting and 
diarrhoea grow less frequent, and finally it is left with a slight amount of 
simple diarrhoea and occasional vomiting. These symptoms may become 
chronic, in which case the infant finally dies of exhaustion or from an 
attack of one of the other gastro-enteric diseases, to which it is left very 
susceptible. 

Diagnosis. — The diagnosis of cholera infantum is not difficult if the 



504 PEDIATRICS. 

characteristic symptoms are borne in mind ; these are rapid onset, con- 
stant vomiting, frequent serous discharges, intense thirst, high rectal 
temperature, low surface temperature, collapse, depressed fontanelle, 
sudden loss of weight, and distressed, restless expression, suggesting 
speedy death, all developing in from twenty-four to forty-eight hours. 

Prognosis. — The prognosis is bad. The more violent the attack, the 
higher the temperature, the less the vitality, and the warmer the weather, 
the worse is the prognosis. When the infant has survived the very acute 
symptoms which appear in the first two or three days, the prognosis is 
much more favorable. 

Treatment. — Cholera infantum is so formidable in its attack that it 
must be treated most energetically if Ave hope to succeed in saving the 
infant's life. The indications for treatment are (1) to assist the effort which 
nature is making to free the stomach and intestine from the poison which 
is in them ; (2) to restore the surface circulation, which is so seriously in- 
terfered with ; (3) to supply water to the tissues, which are being drained 
to so grave an extent ; and (4) to support the strength until the disease 
has run its course. 

The poison seems to act with especial virulence on those portions of 
the economy where it is most concentrated, — namely, the stomach and 
the intestine. We therefore have at first extreme irritation of these parts,, 
which causes increased peristalsis, and later vasomotor paralysis, with 
great transudation of serum. This condition of the gastro-enteric tract is 
to be especially borne in mind during the whole course of our treatment. 

In this disease we should not attempt to use any remedy which works 
slowly. The condition of the mucous membrane is in all probability 
such that absorption of drugs does not take place readily. The adminis- 
tration of drugs is, therefore, contraindicated, for they may later, when 
absorption is being restored, prove fatal by their cumulative action. 
During the acute stage of the disease the digestive functions fail to act, 
and therefore food of any kind will be only an additional source of irri- 
tation. 

Early in the attack, and when the vomiting has not caused much 
prostration, the stomach should be thoroughly washed out with warm 
water and the intestine should be irrigated. If the rectal temperature is 
very high, ice-cold water may be used for irrigation. When the vomiting 
has continued for some time and there is prostration with great thirst, the 
infant should be allowed to suck sterilized ice-cold water from the bottle. 
At first nothing else should be given by the mouth. 

The infant should be placed at once in a warm pack. This should 
be done by wrapping it to the chin in sheets wrung out of water at least as 
hot as 38° C. (100.4° F.). It should then be enveloped in a hot blanket. 
This procedure should be repeated as often as the infant shows signs of 
collapse or much cyanosis and coldness of the skin. This is the best 
method that I know of to restore the surface circulation. In extreme 



SPECIFIC INFECTIOUS DISEASES. 505 

cases the subcutaneous injection of normal salt solution can be tried. 
Care should be taken not to introduce in fifteen minutes more than 37.5 
ex. (1 drachm) for every pound of the child's weight. 

While the infant is in the hot pack, water can be given freely by the 
mouth, and, if necessary, small and frequently repeated doses of stimu- 
lants, unless they appear to excite vomiting, in which case they should be 
given hypodermically. 

If the vomiting and diarrhoea continues to be excessive after this treat- 
ment, small doses of morphine, 0.0006 gramme ( T -J-o grain), and atropine, 
0.00008 gramme (jfa § Tam )i for an infant a year old, can be tried hypo- 
dermically. The effect should be carefully watched, and the dose re- 
peated if necessary. 

If, after the vomiting and diarrhoea have ceased, the heart's action 
continues very weak and does not respond to stimulants, small doses of 
digitalis should be given. The greatest caution should be employed in 
using drugs, however, as they generally do more harm than good. 

If an absolutely fresh and sterile milk can be obtained, it can be used 
as a food, as in any of the other forms of gastro-enteric diseases which I 
have already described, but for some days the percentages of the elements 
in the milk must be much lessened, and the child's strength must be sup- 
ported mostly by stimulants freely diluted with sterilized water. 

CHOLERA ASIATICA. 

Cholera Asiatica is a highly infectious disease, caused by the comma 
bacillus of Koch, which manifests its most violent symptoms in the gastro- 
enteric tract. Its symptoms very closely resemble those of cholera in- 
fantum. The disease in infants should be diagnosticated from cholera 
infantum by finding the comma bacillus in the vomitus or in the dis- 
charges. There are no especial differences between cholera Asiatica in 
the adult and the same disease in the infant. It is exceedingly fatal during 
infancy and childhood, and young infants who are attacked by the disease 
during a cholera epidemic seldom live. The treatment is the same as that 
which has just been described for cholera infantum. 

PERTUSSIS. 

Pertussis (whooping-cough) is a highly infectious disease, affecting 
the respiratory tract, characterized by periods of spasmodic coughing, suc- 
ceeded by a prolonged inspiration and accompanied by a peculiar sound 
called the "whoop. 11 

Etiology. — The cause of pertussis is probably a micro-organism, but 
this organism has not yet been definitely determined. 

Zusch found in twenty-five cases peculiar small bacteria in the sputa. 
They were sometimes seen in clumps, or masses, or in leucocytes. They 
were more numerous in uncomplicated cases, while when marked bron- 



506 • PEDIATRICS. 

chitis or pulmonary complications supervened they diminished in number 
and were replaced by other organisms. This, according to Wright, seems 
to indicate that the organism does not infect the lungs. It is described as 
a short, small-sized bacillus, which grows on ordinary culture media. 
Animal experiments with the bacillus have so far given no positive re- 
sult. Koplik, Czaplewski, and Hensel have also described a bacillus in the 
sputum which may possibly be the specific organism, but its connection 
with the disease is still open to doubt. 

It is supposed that the contagium can be carried by a third individual, 
but usually it is directly communicated from one person to another. 
This contagium is probably contained in the expectoration, and in this 
way the disease may become a source of infection. The disease com- 
monly occurs in epidemics during the winter and spring. Sporadic cases 
occasionally appear, and in large cities the disease is often endemic. Per- 
tussis seems to have some especial relation to measles, as children with 
the latter disease are liable to contract pertussis, and in like manner those 
with pertussis are liable to contract measles. Children with pertussis are 
also especially vulnerable to the tubercle bacillus. Pertussis may occur 
at any age, but it is especially apt to attack the very young infant, and the 
disease has even been known to be contracted in utero. One attack 
usually protects from a second. Debilitated children with catarrh of the 
respiratory tract are more subject than others to the contagium of pertussis. 

Incubation. — The period of incubation is not definitely known, but is 
estimated at from one to two weeks. The disease may be transmitted 
from one patient to another from the beginning of the catarrhal symptoms. 

Pathology. — There are no pathological lesions distinctive of uncom- 
plicated pertussis. The condition which characterizes the paroxysmal at- 
tacks is extreme congestion of the different organs, such as the meninges, 
the lungs, the heart, and the kidneys. In grave or fatal cases the lesions 
are those which arise either from mechanical accidents, as emphysema or 
hemorrhage in various parts, as the eye or the meninges, or from such 
complicating diseases as broncho-pneumonia with its accompanying bron- 
chitis and atelectasis. The bronchial nodes are often found to be en- 
larged. An examination of the blood generally shows an early and 
marked increase in the white corpuscles in which the lymphoid cells 
predominate. 

Symptoms. — It is customary to divide the disease into three periods, — the 
catarrhal stage, the spasmodic stage, and the stage of decline, but any such 
differentiation is arbitrary and inexact, as all three periods overlap to a 
considerable degree. The symptoms in the beginning, and often for 
several weeks, are simply those of a bronchial catarrh with a slight rise 
of temperature and a cough which, although sometimes spasmodic, is often 
indistinguishable from that of an ordinary bronchitis. After a period 
varying from a few days to two or three weeks, the cough becomes more 
severe and of a more decidedly spasmodic character, and the peculiar 



SPECIFIC INFECTIOUS DISEASES. 507 

whoop which characterizes the disease appears. The cause of these 
paroxysms seems to be a spasm of the larynx. This is accompanied by 
a feeling of suffocation. The paroxysm begins with a number of short, 
spasmodic, expiratory coughs, succeeded by a long-drawn inspiration and 
by the peculiar whoop. During the paroxysm, especially in severe cases, 
the face and mucous membranes become cyanotic, the eyes protrude, the 
conjunctivae are congested, and the child looks as though it would die of 
asphyxia. After a few seconds the child, with a convulsive cough, expels 
some tenacious mucus, and is then relieved, or the attack returns again, 
and again subsides, and the symptoms of asphyxia pass away. These 
paroxysms are often followed by vomiting. They may occur only four or 
five times in the twenty-four hours, or again much oftener, — at times 
thirty, forty, or fifty times. At the onset of the attack the children are 
usually very much frightened, and either run to the mother or nurse for 
aid, or go to some part of the room where they can be undisturbed during 
the attack. In certain children, after the severe paroxysms have lasted 
for some time, a small ulcer is formed on the frsenum of the tongue, from 
being driven against the edge of the lower teeth during the paroxysms. 
During the course of the paroxysmal stage of pertussis it is quite common 
to have subconjunctival hemorrhages ; rarely deeper-seated hemorrhages 
take place in the meninges and in the deeper parts of the eye. In pro- 
tracted cases petechias sometimes appear in the skin. Epistaxis may also 
occur. 

Examinations of the chest during the attack have shown that the pul- 
monary resonance is lessened during the expiratory stage and is clear 
during the prolonged inspiration. The auscultation usually shows dimi- 
nution or absence of the respiratory murmur. Bronchial rales are heard 
occasionally. 

Koplik has noticed an increase in the area of the relative cardiac dul- 
ness during the paroxysmal stage of pertussis, which is often accompanied 
by a slight blowing murmur limited to the apex of the heart. This may 
well occur from the engorged condition of the right side of the heart, 
which subjects the heart to a great strain and may thus result in dilata- 
tion. The heart-sounds are apt to be irregular during the paroxysm, and 
in protracted cases during the intervals the pulse is often irregular and 
accelerated, while the respirations are not especially increased unless some 
complication has arisen. In severe cases of pertussis the kidneys are 
sometimes congested, as shown by the appearance in the urine of albumin, 
casts, and blood-cells. Sugar has also been frequently found. 

After the disease has lasted for some weeks there is usually a certain 
amount of oedema of the face, especially under the eyes. The paroxysms 
are precipitated by nervous excitement or by an irritation in the throat or 
the respiratory tract, such as may result either from swallowing or from 
the inhalation of dust. The stage which is accompanied by the whoop 
and the more exaggerated paroxysms commonly lasts for three or four 



508 



PEDIATRICS. 



weeks or even longer. The paroxysms then become less severe, and, 
although the cough continues, the whoop gradually becomes less frequent, 
and after three or four weeks ceases entirely. When uncomplicated, the 
duration of the disease is usually three or four months. Slight changes 
in the atmosphere or exposure will give rise to a relapse. The relapses, 
however, are not, as a rule, of a severe type, and in these cases the cough 
seems to arise from renewed irritation of the sensitive mucous membrane 
of the respiratory tract rather than from a fresh infection by the specific 
germ. A persistent cough following an attack of pertussis may sometimes 
be caused by an insidious form of broncho-pneumonia. 




Pertussis during paroxysm. Female, 4 years old. 



Fig. 117 represents a child during a paroxysm of coughing in pertussis. She had 
just begun to cough, had become decidedly cyanotic, and was aiding the expiratory 
effort by bending forward and placing her hands on her knees at the moment the photo- 
graph was taken. 



The period of infection is supposed to last for a certain time after the 
whoop has ceased, and if the cough continues it is Avell to allow for a 
period of infection of three weeks after this cessation. It is possible, 
however, that the whoop may occasionally occur for long periods after 
the child has ceased to be a source of infection to other individuals. 

Complications. — The complications which arise in pertussis are usually 
of a grave nature. The dangers from hemorrhages, unless in the form in 
which they occur in the meninges, are not great. The complication of 



SPECIFIC INFECTIOUS DISEASES. 509 

broncho-pneumonia is very serious, and often fatal. The especial suscep- 
tibility of these cases to the development of some form of tuberculosis, 
especially a tubercular broncho-pneumonia, renders the stage of con- 
valescence or decline one which demands most careful observation. 
Severe and even fatal emphysema may occur in pertussis. 

Convulsions may arise not infrequently in infants and end fatally. 
They are usually caused by general reflex disturbance, by cerebral con- 
gestion, or by some cerebral lesion. Spasm of the glottis may also very 
rarely cause death in greatly debilitated children. Excessive and obsti- 
nate vomiting at times becomes a serious complication, and may reduce 
the child's strength to a point which often gives rise to a doubt as to its 
recovery. It is an especially grave complication in infants who are already 
much debilitated. Grave intestinal complications are liable to occur, 
especially in the summer, and a pronounced atrophic condition is not 
uncommon when the disease is at all prolonged. 

Diagnosis. — The diagnosis of pertussis cannot, as a rule, be made until 
the child whoops. Sometimes, however, when another child in the 
family has undoubted pertussis, a spasmodic cough may allow the diag- 
nosis to be made before the whoop has developed. It is probable that a 
child may have pertussis without at any time developing the whoop. In 
doubtful cases an examination of the blood in reference to the presence 
of an increased white blood count consisting largely of lymphocytes may 
aid in making the diagnosis. 

In some children a simple catarrhal laryngitis will simulate pertussis 
quite closely ; but, although in these cases there are paroxysms of spas- 
modic coughing, a pronounced whoop does not occur, and the symp- 
toms do not progressively increase and last for a long period. The diag- 
nosis of pertussis can usually be made by the swollen aspect of the face, 
the paroxysmal cough followed by the expulsion of tough mucus and 
vomiting, and the long duration of the attack. 

Prognosis. — Pertussis is a very serious affection in young infants, and 
also in older children who are debilitated or poorly cared for. When 
it is complicated it is one of the most fatal diseases which occur in early 
life. When it occurs in older children the prognosis is favorable, pro- 
vided that they have previously been well and strong, that they are well 
cared for, and that no complications arise. 

In some cases young infants, if their vitality is unusually good, and if 
they are carefully nursed and made to take a sufficient amount of food, 
show remarkable powers of resistance during attacks of pertussis. 

A case of this kind that came under my care was that of an infant five months 
old. In March she suffered from an attack of epidemic influenza, which lasted about 
twelve days, and from which she finally recovered. She was then attacked with 
measles, and after the temperature had fallen to the normal point she was taken with 
pertussis. After two or three days the cough increased in severity, and after two 
weeks the infant began to whoop. The attack lasted for two months, and she finally 



510 PEDIATRICS. 

recovered. During the whole course of the disease she took over 600 c.c. (20 ounces) 
of modified milk in the twenty-four hours, and for a short time small doses of brandy 
were given. No drugs were administered. The temperature varied from 37.2° to 
37.7° C. (99° to 100° F.). 

Prophylaxis. — Pertussis is so highly contagious a disease, and may be 
so serious an affection in certain children, that a rigid prophylaxis should 
be enforced. It is the duty of those who take care of children with per- 
tussis to see that they are isolated during the whole course of the 
disease. 

Treatment. — In the treatment of pertussis we must take into con- 
sideration the age of the individual, the stage of the disease, and the pres- 
ence or absence of complications. In the early months of life, after the 
disease has lasted for a week or ten days and has become more severe, 
the infant will usually show symptoms of general circulatory disturbance. 
The great strain thrown upon the heart during the paroxysms quickly 
affects the general strength of the infant, a marked interference with its 
nutrition soon appears, it loses in weight, and often refuses its food. At 
times it will become somewhat cyanotic even between the paroxysms, and 
there is danger not only from the severity of the paroxysm, but also from 
the vitality of the infant, which may be so much interfered with as to 
prevent its recovery. In cases of this kind the nursing is of the utmost 
importance. The infant should never be left alone, should always be 
taken up whenever a paroxysm is approaching, and should be assisted in 
appropriate ways until the paroxysm is over. Holding the infant in dif- 
ferent positions, sometimes bending the head and body forward at the 
end of the paroxysm so as to aid by gravity the expulsion of the tenacious 
mucus, is desirable. At times, also, the finger covered with a thin cotton 
cloth can be quickly introduced into the throat and the mucus withdrawn 
in this way. It is of the utmost importance that the infant should be 
surrounded continually by fresh air. For this purpose two rooms should 
be used, if possible, one of which should have all the windows thrown 
wide open, so that the air can be completely changed before the infant 
is brought into it, and the patient should be alternately taken from one 
room to the other, the temperature of the rooms being kept as equable as 
possible. 

The nutrition of the infant is so easily affected that the utmost atten- 
tion should be paid to the administration of the food. Small quantities 
of a milk carefully modified to suit its digestion should be given at frequent 
intervals, preferably after the occurrence of a paroxysm, as it is then more 
likely to retain the milk in its stomach a sufficient length of time for it to 
be absorbed before the next attack. The amount of food which the infant 
retains in the twenty-four hours is an important factor in the treatment. 
In infants of from six to twelve months at least 600 to 750 c.c. (20 to 25 
ounces) of milk should be taken arid retained in the twenty-four hours. 
When the amount is lessened to 360 or 450 c.c. (12 or 15 ounces), the 



SPECIFIC INFECTIOUS DISEASES. 511 

infant's nutrition, as a rule, suffers to such an extent that unless this 
amount can be increased a fatal issue is likely to result. 

Stimulants, in the form of brandy or whiskey, should be given early in 
the attack. When the cyanosis is a prominent feature and the pulse is 
irregular and intermitting, small doses of digitalis should be given, adapted 
to the age of the child, as in Table 64, on page 486. In these cases, 
also, the administration of oxygen is a valuable adjunct to the treatment. 
At the height of the attack, when the paroxysms are severe and espe- 
cially frequent at night, the burning of cresoline in the room at night is 
sometimes beneficial. In the milder forms of the disease which are not 
accompanied by the more severe symptoms just enumerated, belladonna 
or atropine often proves valuable. There is no drug, however, which is 
a specific for pertussis at any age. 

For older children whose health has previously been good, there is 
no especial treatment, except that they should have as much fresh air, 
free from dust, as possible, and that food should be given them after they 
have vomited. 

When complications arise, the treatment is that of the complicating 
disease. 

In cases which are protracted, a change of air, either to the country or 
to the sea-shore at suitable seasons, is often followed by an apparent 
shortening of the duration of the attack. 

In some cases, even in older children and where no complications are 
present, the attack of pertussis may be so severe as to prove serious. 
Northrup reports the case of an infant, under one year of age, who died 
during a violent paroxysm in pertussis, and in whom the autopsy showed 
extensive vesicular emphysema with great distention of the walls of the 
alveoli. The following case occurred in my practice : 

A boy, six years old, had had pertussis for five weeks. For two weeks previous 
to my seeing him the cough had been so frequent and so constantly accompanied by 
vomiting that the child had been unable to retain any food. He was very much ema- 
ciated, and was so weak that he could not stand. This condition lasted for a week 
or ten days : he then began to improve, and finally recovered entirely. There were no 
complications. 

ACUTE INFECTIOUS OSTEOMYELITIS. 

Acute infectious osteomyelitis is an acute arthritis attended by sup- 
puration at the joints. It has been described under various other 
names, such as acute arthritis of infants, acute purulent synovitis of infants, 
acute epiphysitis, and pycemia of the bone. 

Etiology. — Nichols has shown that acute infectious osteomyelitis is 
an acute inflammation of bone due to any one of a number of patho- 
genic organisms, hence osteomyelitis is not a specific disease, but belongs 
to the group of septic pyaemias. The staphylococcus pyogenes aureus is 
the organism that most commonly produces the disease. An early period 



512 PEDIATRICS. 

of development and the exanthemata predispose to osteomyelitis. Trau- 
matism must be recognized as an exciting cause. 

Pathology. — In infants the disease commonly originates from a septic 
infection of the umbilicus or pharynx. The process attacks the bone- 
marrow primarily, and the joints become secondarily involved if the 
process originates or extends to the end of the bone and is not limited 
by the shaft. The joint infection may come either from separation of 
the epiphysis, which is wholly or in part intra-capsular, or from a growth 
of pyogenic organisms along the blood- or lymph-channels of the epiph- 
ysis, frequently setting up an osteomyelitis of the ossified portion of 
the epiphysis and spreading thence into the joints. The two affections, 
therefore, represent different phases of bone infection, rather than 
different diseases of the bone. The morbid process sometimes involves 
the entire structure of the bone, including the periosteum. 

Osteomyelitis begins as a hyperemia of the bone-marrow. Later, 
suppurative foci of a dull-yellow or grayish color appear, while in severe 
cases the entire marrow becomes purulent and the Haversian canals of 
the cortical portion become filled with pus. Metastatic abscesses and 
thrombosis of the veins of the marrow may follow. When the infection 
enters the joint the cartilage is softened and destroyed and an abscess is 
formed. Osteomyelitis may, however, be the cause not only of a sup- 
purative but of a simple inflammation of the joint. 

Symptoms. — The onset is sudden and sometimes marked by a chill. 
There are severe constitutional symptoms of fever and intense pain 
usually sharply localized. The part affected is swollen, reddened, and 
tender, and if a joint itself is involved, the swelling which is at first 
tense soon becomes fluctuating. From the beginning of the disease the 
signs of sepsis are manifest by the high intermittent fever, rapid pulse, 
pronounced leucocytosis, and great prostration. In exceptional cases 
these severe constitutional symptoms may not be present. In rapid cases 
death may occur in three or four days, but the disease is generally pro- 
longed for one or two weeks. 

Diagnosis. — The differential diagnosis is to be made chiefly from 
articular rheumatism, from which it is to be distinguished by the sur- 
rounding soft parts being much less involved and the general symptoms 
much more severe in osteomyelitis, and, if the disease occurs in the first 
two years, by the rarity of rheumatism at so early a period. 

From tuberculosis, osteomyelitis is to be differentiated by the slow 
onset of the former and the primary lesion generally showing itself in the 
shaft of the bone in the latter, while in the former the epiphysis is usually 
first attacked. The process of osteomyelitis may, however, attack the 
epiphysis and extend to the joint. The presence of a leucocytosis in 
osteomyelitis is also of great aid in the diagnosis. 

Prognosis. — The prognosis is very unfavorable unless immediate and 
radical surgical interference is carried out. 



PLATE VII. 




Osteomyelitis of the lower end of the femur, with spontaneous fracture. Boy, 9 years old. A, lower 
end of upper fragment ; B, upper end of lower fragment ; C and D, portions of cortical bone which have 
been sequestrated, and were subsequently removed by operation ; E, callous tissue. 






Tumor albus of three years duration in a girl of 6% years. The destruction of bone tissue is mainly 
confined to the external half of the epiphysis of the femur and to the adjacent portions of the diaphy- 
sis. A, subcutaneous cheesy abscess, communicating with the diseased area of the bone ; B, probably a 
sequestrum surrounded by necrotic tissue ; C, shows enlargement and squaring of epiphysis of tibia, as 
compared with the normal, indicating congestion and proliferation before absorption of the bone tissue 
has begun. 



SPECIFIC INFECTIOUS DISEASES. 513 

Treatment. — The treatment is essentially surgical. Where osteomye- 
litis of the shaft of a long bone is found at operation, all of the affected 
portions should be removed, even if a considerable portion of the shaft 
is taken, experience having shown that new bone will soon form, and that 
a serviceable limb is the usual result in the leg and forearm. 

Prevention of septic infection of the umbilical cord, and of the wound 
after the cord has fallen off, is important as a matter of prophylaxis. 

The following case came under my observation at the Infants' Hospital : 

An infant, one month old, was admitted to the hospital November 16. The 
parents, who were Italians, were seemingly healthy and had one other child, a girl, 
who was also reported to be healthy. One week previous to entrance, what was 
described as a "red rash" appeared on the abdomen and spread down the left leg. 
It lasted about four days. Two nights previous to entering the hospital the infant 
had cried seemingly from pain on movement of the legs. There had been some dis- 
charge of pus from the umbilicus which had never healed. The infant appeared to 
be well nourished and of good color, with no abnormal appearances, excepting that 
the umbilicus had not healed, and also that the lower third of the left thigh was 
swollen so as to be twice as large as the right thigh, and that the skin in this region 
was red and shiny. The left leg was held stiffly and somewhat flexed, the knee being 
bent almost at a right angle, and both in front and over the anterior tibial group of 
muscles and over the calf there was a brawny feeling without fluctuation or localized 
tenderness. 

On the day following entrance, the brawny infiltration was less extensive. The 
temperature, however, remained over 40° C. (104° F.). On November 19, a vertical in- 
cision was made from the inner side of the head of the tibia about four inches down- 
ward. This revealed a tibial abscess under the periosteum, which was separated for 
two inches both in front and behind. The cartilaginous epiphysis was separated and 
freely movable, and the bone of the shaft was red, rough, soft, and covered with small 
bleeding points. The upper two inches of the shaft were removed, revealing what ap- 
peared like hard, healthy bone. A counter-opening was made in the calf, and after 
irrigation a sterilized dressing was applied. The temperature continued between 39° 
and 40° C. (102.2° and 104° F.). 

On changing the dressing in the afternoon, the lower surface of the upper epiphys- 
eal cariilage looked gray and opaque, but at the next dressing several bleeding points 
were seen in the epiphysis and the wound looked well. A swelling had suddenly 
appeared over both malleoli, and an incision let out some greenish pus. A small area 
of the bone was curetted at this time. 

Some hours later a swelling appeared over each wrist, which was drained by two 
incisions, one over each styloid process. No communication was found with the bare 
bone. The skin was found to pit on pressure, and to be slightly reddened over the 
biceps. 

On the following day, November 22, the infant was found to be jaundiced. 
Fluctuation appeared and the arm was freely opened from the coracoid process to the 
elbow. An opening was also made at the posterior border of the deltoid, as pus was 
discovered along the long head of the biceps. The shoulder was then irrigated and 
drained. 

The cultures which were taken from each of these abscesses showed no growth 
excepting the one from the tibia, where staphylococcus aureus was found in abundance. 
It was afterwards noted that this growth had not been found elsewhere because the 
oven where the cultures had been baked had been overheated. 

On the following morning the hand and arm were blue, cold, and swollen. No 

33 



514 PEDIATRICS. 

pulse could be felt, and the tissues in the wound were almost black. The child died 
nine days after the first symptom pointing to an affection of the bone. 

The autopsy was made three hours after death, and was interesting in that it 
showed no abscesses which could not be traced to multiple osteomyelitis. There was 
almost entire absence of pathological changes in the viscera. A separation of the 
epiphysis had occurred at the lower end of the left tibia and fibula, the upper end of 
the left femur, the lower end of both radii and ulnae, and the upper end of the right 
humerus, with softening of the bone and pus. No thrombi were found in the right 
axillary vessels, the whole right arm to the wrist being swollen and discolored, and on 
cutting into it a red serous fluid flowed out of this phlegmonous inflammation. Cul- 
tures from the heart's blood, kidneys, and liver showed no growth, but from the hip- 
joint and tibial marrow there was an abundance of pure staphylococcus aureus, and 
from the phlegmonous arm a faint growth of streptococci. Blood-serum was the cul- 
ture medium. 

The case showed a rapid septic infection confined to the bone-marrow and bone of 
the shafts. Several long bones were affected, unaccompanied by any inflammation of 
the lymphatic glands or of the internal organs. 

Pure cultures of staphylococcus aureus were obtained from the left tibia and hip, 
and as there was no discernible difference in the appearance of the three bones, it is 
probable that the same micro-organisms had existed in all the inflamed bones. The 
streptococcus infection of the arm was probably due to accidental inoculation at the 
time of the operation. The shoulder- and hip-joints contained pus, but the knee and 
wrist escaped. This is to be explained by the anatomical relation of the epiphysis to 
the capsule of the joint. When the epiphyseal line reaches within the joint-capsule pus 
can reach the joint whenever the epiphysis is separated by suppuration, and this rela- 
tionship existed in the hip- and shoulder-joints. In the wrist the capsule is inserted 
into the epiphysis of the radius and ulna, and not into the shaft, so that pus to reach 
the joint has to perforate the cartilaginous epiphysis. This is more difficult than 
when the suppuration can pass directly from the epiphysis into the joint. The same 
is true of the upper epiphysis of the tibia, for the capsular ligament of the knee does 
not cross the epiphysis but is inserted into it, therefore, when separation occurs, the 
pus burrows under the periosteum, but does not break into the joint. 



RHEUMATIC FEVER. 

Rheumatic fever (acute articular rheumatism) is an acute infectious 
disease, non-contagious, affecting usually a number of joints, and showing 
a tendency to inflammation of the endocardium and pericardium. 

Etiology. — The cause is unknown, but there is such an intimate rela- 
tion between articular rheumatism and endocarditis, a disease which has 
been proved to be of bacterial origin, that the disease is now considered 
to be produced by some specific organism. Tonsillitis is such a frequent 
initial symptom that it is possible that it may be the point of entrance 
of the infection. Although acute articular rheumatism may occur at any 
age, it is very rare in infancy, and comparatively rare in early childhood. 

The subacute attacks, characterized by a moderate heightening of the 
temperature and milder symptoms, may occur in children, and are more 
apt to be complicated by endocarditis and pericarditis in childhood than 
in adult life. They may last for many weeks and finally become chronic. 
Exposure to dampness, to cold, and to sudden and great changes in tern- 



SPECIFIC INFECTIOUS DISEASES. 515 

nerature are important predisposing causes. One attack predisposes to 
another. 

The symptoms are so varied and so similar to those of a septic infec- 
tion, as evidenced by the character of the fever, the involvement of the 
serous membranes, the tendency to relapse, the sweats, and the leucocy- 
tosis, that it corresponds closely to the type of an acute infection. 

Pathology. — There are no lesions which especially characterize the 
pathology of the disease. According to Osier, the affected joints show 
hyperemia and swelling of the synovial membranes and of the liga- 
mentous tissues. There may be a slight erosion of the cartilage. The 
fluid in the joint is turbid, albuminous in character, and contains leuco- 
cytes and a few fibrin flakes. An extensive effusion into the joint is, how- 
ever, uncommon. Pus is very rare in uncomplicated cases. The blood 
usually contains an excessive amount of fibrin. In the secondary rheu- 
matic inflammations, such as pleurisy and pericarditis, various pus organ- 
isms have been found, possibly the result of a mixed infection. 

Symptoms. — During the first two years of life rheumatic fever is ex- 
ceedingly rare, but may occur. Up to eight years of age the type of the 
disease is essentially different from that of the adult. There may be slight 
swelling only, and redness and tenderness of the joints may be entirely 
absent and the temperature only slightly elevated. The only symptoms 
are likely to be stiffness of one or more joints with pain on motion, or 
sometimes with indefinite wandering pains which are not referred to the 
joints. In these cases with obscure symptoms, the hereditary predispo- 
sition to rheumatism, the history of previous attacks, and the presence of 
endocarditis or pericarditis which cannot be explained on other grounds 
are important points in making the diagnosis. 

The onset of the disease in children above eight years of age is usu- 
ally acute, and is characterized by loss of appetite, fever, swelling, ten- 
derness, and redness of one or more joints. Pronounced redness and 
swelling of the joints are not so marked as in adults. The temperature 
and pulse are usually moderate, although in the beginning of the attack, 
following the rule of acute infectious diseases, a sudden rise of tempera- 
ture to 39.4° to 40° C. (103° to 104° F.) is not uncommon. The pulse 
and temperature soon fall several degrees in the course of the disease, 
and then gradually become normal, unless some complication arises. The 
urine is diminished, high-colored, and very acid. On cooling it deposits 
urates. The chlorides are diminished. A characteristic symptom is pro- 
fuse and acid sweating, having a sour odor. The mind is usually clear. 
The joints are apt to be invaded successively, the joint first affected some- 
times becoming decidedly less painful and swollen as the next joint is 
involved. Anaemia develops rapidly, and leucocytosis is usually marked. 

Complications. — The most frequent complication of articular rheuma- 
tism in children is endocarditis. The onset of the complication is usually 
characterized by precordial pain, rise of temperature, and, on physical 



516 PEDIATRICS. 

examination, a soft-blowing systolic murmur of mitral origin. Although 
hsemic murmurs may develop in the course of acute articular rheumatism, 
an endocarditis is so much more common that the presence of a murmur 
should be looked upon as a possible grave lesion in every case, and the 
heart should be carefully examined at each visit for the purpose of detect- 
ing any abnormal sound as soon as it is perceptible. In some cases the 
endocarditis begins very insidiously without noticeable symptoms referable 
to the heart, and in children there is a special tendency to dilatation. 

Next to endocarditis the most frequent complication is pericarditis, 
which begins with a pericardial friction-rub, usually under the middle or 
upper part of the sternum, with pain and precordial distress, and later 
with the usual mechanical symptoms of dyspnoea and orthopncea, as de- 
scribed under pericarditis. The disease is often associated with endo- 
carditis, but does not usually occur at so early an age as endocarditis, the 
middle period of childhood being most prone to the disease. Especial 
mention should be made of the delirium connected with pericarditis. 
When a pericarditis is accompanied by effusion, the fluid, in children, is 
especially likely to be purulent. Of the other more rare complications 
can be mentioned myocarditis, pneumonia, pleurisy, and peritonitis, also 
certain cerebral complications usually associated with hyperpyrexia and 
represented by delirium, coma, and convulsions. The relation between 
chorea and rheumatism is stated on page 917. 

Various forms of erythema appear in the course of rheumatism. A 
rather uncommon symptom in this country, although seemingly more 
frequently met with in England, is the development of small subcuta- 
neous fibrous tumors attached to the tendons and fasciae in any part of 
the body or limbs. 

Diagnosis. — The diagnosis of rheumatic fever is made by the presence 
of the characteristic symptoms of high fever of acute onset, followed by 
localizing symptoms in one or several joints ; of redness, swelling, tender- 
ness, marked pain on motion, and leucocytosis. The disease is to be 
differentiated from several affections which closely resemble it. 

From Infantile Scorbutus. — Symptoms occurring in the first two years 
of life should be carefully distinguished from scorbutus (page 345). 

From Acute Osteomyelitis. — The diagnosis is made principally by the 
greater intensity of the localizing symptoms, the involvement of the epiph- 
yses or the shaft of the bone, rather than the joint, and the presence of 
more pronounced constitutional symptoms in osteomyelitis. Moreover, 
there is less tendency to a multiple affection of the joints. 

From Multiple Secondary Arthritis. — Infections of the joints may occur 
in connection with gonorrhoea, scarlet fever, dysentery, and cerebro-spinal 
fever, but the differential diagnosis can usually be made without diffi- 
culty by the course of the symptoms, the tendency to involve but one 
joint, and the recognition of the disease in which the arthritis occurs as a 
complication. 



SPECIFIC INFECTIOUS DISEASES. 517 

Prognosis. — The prognosis of rheumatism in children is very favor- 
able, unless complications arise, in which case it depends upon the 
severity of the complication. Endocarditis and pericarditis make the 
prognosis especially grave, as rheumatic attacks are liable to recur, and at 
each recurrence the cardiac lesions show a tendency to become more 
pronounced and serious. 

Treatment. — The child should be kept in bed, and made to wear soft 
flannel night-gowns so fashioned that they can be changed with as little 
disturbance as possible, and fresh gowns should be put on as often as 
severe sweats occur. It is desirable that patients should sleep between 
blankets in preference to sheets. Milk is beyond doubt the most appro- 
priate diet. The thirst can be satisfied by lemonade, or oatmeal- or barley- 
water. Soups and broths may be used to vary the milk-diet. 

There are no drugs which act directly upon the disease so as to 
prevent its serious complications. For the relief of pain, however, the 
salicylates are especially valuable. They should be given in fairly large 
doses, 0.3 gramme (5 grains), for the first twenty-four hours until toxic 
symptoms, such as slight disturbance in hearing and ringing in the ears, 
are produced, or until the pain has subsided. When the pain is once 
under control, small doses of the salicylates three or four times a day 
will usually keep the patient comfortable. With the fresh involvement 
of another joint, an increase in the quantity of the salicylates may be 
needed temporarily. The ammonium salicylate is perhaps the most 
useful preparation. Salol, salicin, aspirin, and oil of wintergreen (two to 
four minims) may be tried. The alkaline treatment is often effective, and 
may advantageously be combined with the salicylates. Ten or fifteen 
grains of the citrate of potassium in two or three ounces of water, and 
the addition of thirty grains of bicarbonate of soda with a half-ounce of 
lemon-juice, makes an agreeable effervescent drink. This may be given 
every three or four hours until the urine is slightly alkaline, and then in 
such quantities as to keep the reaction just perceptibly alkaline. 

Phenacetine in small doses, 0.06 to 0.12 gramme (1 to 2 grains), 
guarded with stimulants, may be used to control exacerbations of pain 
when it is not desirable to increase the salicylates. Especial attention should 
be directed to the heart, and its complications treated symptomatically. 

The local treatment of the joints, in the acute stage, consists in the 
application of hot laudanum fomentations for the relief of pain. The 
weight of the bedclothes should be kept off the affected joints by means 
of a cradle. When the pain has subsided, the joints should be wrapped 
in cotton-wool. When the process has become subacute or chronic, great 
improvement, as evidenced by diminution in the swelling, stiffness, and 
pain on motion, often follows the application of dry heat for an hour 
every day or several times a week. This may best be applied by the 
ovens especially adapted for the purpose. 

The disease will generally run a course of from four to six weeks, 



518 



, PEDIATRICS. 



during which time the patient should generally be kept in bed, and care 
be taken to maintain an equable temperature in the room. Owing to 



Pig. 118 






Acute articular rheumatism. Adult type of disease. Male, 3% years old. 

the tendency to a recurrence of the disease, it is often advisable to re- 
move the child to a warm, dry climate during the cold and unsettled 

weather which prevails in the winter and early 

spring in the North. 

The following cases illustrate rheumatic 



CHART 19. 



DAYS OF DISEASE 


F. 


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10 


11 


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13 


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fever 



A boy, three years and four months old, was treated 
in the hospital for bronchitis, and when convalescent 
from that disease was attacked with acute articular rheu- 
matism. 

There was no rheumatic history in his family, and 
he had never had rheumatism nor any other disease ex- 
cept bronchitis. After having been feverish for two 
days, the temperature varying from 37.7° to 38.8° C. 
(100° to 102° F.), he complained of pain and tenderness 
in his shoulders, wrists, and elbows. On the follow- 
ing day these symptoms increased, being especially 
marked in the left hand and left knee. There was an 
expression of anxiety on his face, showing that he feared 
that the tender joints would be touched. The weight 
of the bedclothes was kept from the knee by a cradle, 
and the arm was comfortably arranged on a pillow. 
These details in the nursing of a rheumatic child are 
very important. Fig. 118 shows the affected knees and 
wrist. He was being treated with oil of gaultherium, 
4 minims every three hours. The temperature varied 
from 38.3° to 39.4° C. (101° to 103° F.). An exami- 
nation of the cardiac region did not reveal any cardiac complication. 

The child suffered considerably for four weeks, but at the end of that time the 
joints gradually grew less painful, and he was entirely well thirty-three days from the 
onset of the attack. 



Acute articular rheumatism. 
Acute endocarditis on seventh day 
from beginning of attack. 



SPECIFIC INFECTIOUS DISEASES. 



519 



The next child, a girl, five and one-half years old, was interesting as 
illustrating a number of characteristics in connection with the rheumatism 
of children. 

She was attacked eight days before entering the hospital with pain, swelling, and 
tenderness in her left ankle. On entrance her temperature was 40° C. (104° F.). her 
pulse was 145, and her respirations were 40. There was very slight pain in the joints, 
and, although her appetite was lessened, she otherwise seemed well, and had not com- 



Fig. 119. 





ibcutaneous fibrous nodules. Male, 13 years old. 



plained of any pain since the beginning of the attack. On the sixth day the tempera- 
ture fell to 37.2° C. (99° F.). It is interesting to note the extreme latency of the dis- 
ease, and how the child seemed to be perfectly comfortable from the beginning of the 
attack, except when the ankles, both of which were swollen and tender, were touched. 
On the seventh day of the disease the temperature rose to 38.6° C. (101.5° F.), and 
an examination of the chest showed a mitral systolic murmur. The murmur became 
more marked, and was transmitted into the axilla and the back. The area of superficial 
cardiac dulness was slightly increased, and extended to the middle of the sternum. 

By the end of the second week of the attack the pain and tenderness had left the 
ankles, and the child seemed quite well. The area of superficial cardiac dulness was 



520 PEDIATRICS. 

found to be normal, but the systolic murmur still continued. Chart 19 shows the 
rheumatism gradually subsiding up to the seventh day of the disease, when the endo- 
carditis arose as a complication. 

Fig. 119 represents a boy who during an attack of rheumatism developed the 
subcutaneous fibrous nodules which have been referred to. 

When he was seven years old he had an attack of rheumatism affecting his ankles 
and the muscles of his neck. His temperature was 37.2° C. (99° F. ) ; his urine was 
normal. During this attack a systolic souffle transmitted into the axilla developed, and 
the area of superficial cardiac dulness was increased. This attack lasted eight days. From 
that time until he was thirteen years old, that is for six years following his first attack 
of rheumatic fever, he had more or less dyspnoea on exertion, and at times cardiac pain, 
but never had any marked return of the rheumatism. At the end of that time he no- 
ticed small lumps appearing under his skin. When they were first observed he had 
indefinite pains in his limbs, severe headache, and malaise. Some of the lumps were 
slightly tender, and were distributed on the chest, arms, abdomen, and legs, mostly on 
the anterior surface. 

Although acute articular rheumatism is rare in infancy, I have met 
with a number of cases at this early period of life. Reference has already 
been made, on page 95, to the little girl, two years old, who, after exposure, 
was attacked with acute rheumatism in both hip-joints. Two other cases 
are of special interest on account of their early occurrence. 

The first case was one of rheumatic fever, attacking all the joints, in an infant 
two weeks old, after exposure to a cold draught while being bathed. Any movement 
of the joints caused the infant to scream. He lost rapidly in weight, his surface 
circulation was disturbed, and the attack lasted for four months ; but when he was six 
months old he was perfectly well, and no cardiac complication developed during the 
attack. 

Another case of this kind was an infant who was attacked with rheumatic fever 
when she was seven months old, the attack lasting until she was fifteen months old, 
when she recovered without any cardiac complication, and became well and strong. 

SYPHILIS. 

The specific organism which causes syphilis has not yet been dis- 
covered. The disease as it is manifested in early life appears in two 
forms, — (1) acquired, and (2) hereditary. 

The former differs in no respect from the disease as it occurs in 
adults, and is transmitted by direct infection, usually through one of the 
mucous membranes. Its treatment and general characteristics are the 
same as in adults. 

HEREDITARY SYPHILIS. 

The hereditary form of syphilis plays an important part in the dis- 
eases of the early months of life, and is an affection which in all its 
phases should be thoroughly understood by those who practise among 
children. 

By inherited syphilis we mean a congenital disease which has been 
transmitted to the child through one of the parents or through both. It 
makes its appearance either in the early months of life, syphilis of the 



SPECIFIC INFECTIOUS DISEASES. 521 

new-born, or at a later period towards puberty, retarded syphilis. The 
stage which is met with at birth usually corresponds to an early stage of 
acquired syphilis, while that which is delayed until later childhood or 
puberty corresponds to a later stage. 

Inheritance and Transmission. — The question whether the infant can 
inherit syphilis from the father without the infection of the mother is one 
which has not yet been determined finally. The weight of evidence is in 
favor of the view that its occurrence in this way is not possible. The 
probability is that some mild and transient form of the disease has been 
overlooked in cases where the mother has been apparently healthy, es- 
pecially as the mother of a syphilitic infant is always immune to infection 
by her infant. Instances, however, occur in which it is impossible to say 
that the mother of an undoubtedly syphilitic infant is also syphilitic. The 
following case illustrates this point : 

An infant with marked syphilitic lesions was brought to me for treatment. The 
father of the infant acknowledged having been treated for a primary syphilitic lesion 
which was followed by pronounced secondary symptoms. The mother was a healthy, 
strong woman, who had always been perfectly willing to give any information required 
either as to her own or as to her husband's condition, in order to aid in the preserva- 
tion of her infant's life. She stated that she had never had any miscarriages, that she 
was perfectly well both before and after the birth of this infant, and that she had never 
had an efflorescence on her skin, a sore throat, nor any lesions of the mucous mem- 
branes. She came under my observation when her infant was six weeks old, and 
has since then been seen sufficiently often for me to say that so far as I can determine 
she has had no symptoms that in any way could be attributed to syphilis. She had 
always had a plentiful supply of breast-milk, which was evidently of good quality. 

A syphilitic infant does not infect its mother {Collets law). It can 
infect a woman, however, who either has never had syphilis or who 
has never given birth to a syphilitic infant. 

It is probably possible for a syphilitic foetus to infect its mother in 
utero. This theory of retro-infection, however, has not been universally 
accepted. Fournier believes that there is a class of cases in which the 
father at the time of marriage has no lesion which would necessarily 
infect the mother, where the mother never shows any initial lesion and 
remains free from syphilis so long as she is unimpregnated, and where 
after impregnation she becomes syphilitic and either aborts or gives birth 
to a syphilitic infant. In connection with the subject of retro-infection 
the question arises whether a mother who becomes syphilitic during her 
pregnancy can infect the foetus (post-conceptional syphilis). There is no 
doubt that she may abort from her own syphilitic infection. The same 
authority believes that the foetus is also syphilitic. This doctrine, how- 
ever, is not universally accepted. There is no doubt but that infection 
may take place ; whether it always does is not yet settled. 

It has been found that when a woman is syphilitic it is exceedingly 
common for her to abort. Miscarriage is more frequent when a woman 



522 PEDIATRICS. 

is passing through the early stages of syphilis than later when she has 
become more or less habituated to the disease. The treatment by mer- 
cury in these cases soon after impregnation, and continued during the 
pregnancy, is a valuable means of averting abortion. Although the 
aborted foetus of a syphilitic woman is usually macerated, yet such a 
condition of the foetus may be produced by other diseases as well as by 
syphilis. Birch-Hirschfeld has found from an examination of a large 
number of macerated foetuses that seventy per cent, were undoubtedly 
syphilitic. 

Although the tendency to transmit the disease is greatly lessened by 
time, yet the thorough treatment of the parents by mercury is the most 
efficient means of preventing such transmission, and the careful use of 
this drug in proper doses is never contraindicated. It is, therefore, 
evident that a pregnant syphilitic woman should be treated with mercury 
whether she was infected before or after conception. When both parents 
are syphilitic, and when their syphilis is in the early stages, the infant is 
most likely to inherit the disease, and under like conditions the disease is 
apt to be of a severe type. 

Infants entirely free from syphilis, either at birth or later, have been 
known to be born of parents of whom one or both were undoubtedly 
syphilitic. The following cases illustrate this question of immunity : 

Two children of a family of five were under my care, all of whom were healthy at 
birth and had never shown any symptoms of syphilis. The father was infected with 
syphilis before marriage, and later infected his wife. They were both carefully treated 
with mercury. The wife had never had any abortions. She had had five children, 
and had lost none. Both father and mother had had undoubted secondary and ter- 
tiary lesions, some of which still existed at the time I saw them. 

The father of another such case was a rag-sorter, who had a primary syphilitic 
lesion on his hand twelve years previously. This lesion was followed by secondary 
symptoms. He had never had any lesion on the penis. While he was being treated 
his wife showed symptoms of syphilis and was also treated with mercury. This child 
had always been healthy, and was one of three, none of whom had ever developed 
any syphilitic lesions. 

Pathology. — The pathological tissue-changes which take place in the 
hereditary form of syphilis are of the same nature as those Avhich occur 
in the acquired form. Diffuse interstitial hyperplasia is much more 
common in the hereditary form than are circumscribed gummy tumors. 
Changes in the bones are very common in hereditary syphilis, and in fact 
so much so that it is usually considered necessary to find these osseous 
changes in order to establish a diagnosis of syphilis in the foetus. 

Osseous System. — The changes in the bones which take place in heredi- 
tary syphilis are so important, not only on account of their pathological 
interest, but also because of their clinical significance, that especial atten- 
tion should be paid to them. 

In this connection it should be remembered that in the latter part of 



SPECIFIC INFECTIOUS DISEASES. 523 

intra-uterine life the long bones are cartilaginous and the process of ossi- 
fication is intra-cartilaginous. As the cartilage changes to bone the carti- 
lage-cells increase in number and are closely crowded together. Then 
comes the area of osteoblasts, then the calcareous matter, and deeper 
down in the ossified portions are the blood-vessels running in from the 
periosteum. The epiphyses of the bones of the arm are cartilaginous at 
birth, and they remain separated from the shaft of the bone for some 
time by a narrow cartilaginous layer. It is in this cartilaginous sepa- 
rating layer, called the zone of proliferation, represented in the drawing 
of a normal infant's bone (page 329, Fig. 82 I.), that certain changes are 
found in hereditary syphilis. It is also at this zone of proliferation that 
the growth in the length of the bone takes place, and it is here that 
syphilitic changes are most often found. This lesion is an osteochondritis, 
and may occur together with lesions of the spleen and other parts of the 
body, or as the only manifestation of the disease. 

Osteochondritis is ordinarily the form of bone-disease in infants. 
Osteoperiostitis belongs almost exclusively to the later forms of heredi- 
tary syphilis as they appear in older children and in young adults. 

The bones which are affected most commonly are those of the arms 
and of the legs. 

Besides these common osseous lesions a morbid condition of the 
fingers and toes, called dactylitis, occurs quite frequently. In this condi- 
tion the fingers and toes assume a peculiar pyriform shape. In addition 
to these purely syphilitic changes, local thinning of the bones of the 
skull, called craniotabes, occasionally occurs. In this condition the bone- 
substance is absorbed, leaving only the integuments and membranes. 

Liver. — The liver is always larger than in the normal condition. The 
hepatic tissue is harder and more elastic than usual. The most common 
cause of the condition is a diffuse interstitial nephritis. In other cases 
the enlargement is due to gummata. The liver then is of a yellow color, 
and there are small white granulations scattered throughout the paren- 
chyma. The hepatic acini under normal conditions are in contact, except 
at the prismatic spaces formed by their union, in which spaces the capsule 
of Glisson forms an envelope to the afferent portal vessels of the lobule. 
It is in these spaces that the round lymph-cells form and collect into 
small nodules representing microscopic gummata, which resemble those 
that occur in adults. 

Spleen. — Next to the osseous system the spleen is the part most often 
affected by syphilis. It is enlarged, and the degree of splenic enlargement 
is usually characteristic of the severity of the disease. 

Pancreas. — Birch-Hirschfeld has pointed out the fact that the pancreas 
is frequently found to be affected in hereditary syphilis. He remarks 
that the interstitial changes which he found in the pancreas are analogous 
to those which occur in other organs, especially the liver, and that, while 
these changes are not constant, they come next in frequency to the altera- 



524 PEDIATRICS. 

tions in the spleen. The interference with the function of the pancreas, 
which must occur when it is diseased to any great extent, is probably 
the cause of the gastro-enteric disturbances so common in hereditary 
syphilis. 

Lungs. — In cases of hereditary syphilis born before term, and in those 
born at term who live but a few days, the lungs present certain patho- 
logical conditions represented by nodules or small tumors, usually super- 
ficial and varying in size. Sometimes an entire lobe may be involved, 
and the dense, altered lung-tissue is colorless gray or white, both on its 
surface and on its section. This condition has been called by Virchow 
pneumonia alba, white hepatization. 

Kidney and Testicle. — The kidney and testicle may show the lesions 
of syphilis. It is to be noted that the lesions of these organs are amenable 
to treatment. The disease in the testicle is represented by a gradual 
enlargement, and is usually bilateral. 

Throat, Upper Air-Passages, Thymus Gland, and Heart. — Extensive 
lesions are at times found in connection with the pharynx, larynx, trachea, 
and neighboring parts, and also with the thymus gland and with the 
muscles of the heart. 

Early Manifestations of Hereditary Syphilis. — Symptoms. — -The 
severity of the disease determines the type of the efflorescence, and is 
also influenced by the time when the infection of the foetus took place. 
Thus, the later the period of infection the milder will be the form of the 
efflorescence which first appears, while the less severe the general symp- 
toms the better will be the prognosis and the greater the amenity of the 
disease to treatment. The reverse of these rules is found when the in- 
fection has taken place early, and when, as a result, the infant is born 
dead, or at birth shows such advanced stages of the disease as are repre- 
sented by the more intractable forms of efflorescence and severe general 
symptoms, making the prognosis exceedingly grave. 

In the mild form of the disease the infant may be born apparently 
healthy and may show no indications of its syphilitic inheritance for 
some weeks. It is rare, however, for the symptoms to be delayed beyond 
the first three or four months of life. The earliest symptoms of heredi- 
tary syphilis correspond to the secondary symptoms of acquired syphilis. 
Commonly, unless the infant is born with the efflorescence, it is noticed 
at birth, or within two or three weeks, to have occlusion of the nares 
(snuffles), and, soon after, a hoarse cry and an efflorescence of a macular 
or a papular variety. The efflorescence is general, includes the palms 
of the hands and the soles of the feet, and is especially prominent on the 
forehead. 

The condition of the infant depends considerably on that of the 
mother. The rule is that these infants when born are emaciated, but I 
have seen them well developed and apparently in good condition. The 
disease, with appropriate treatment and good feeding, may in some cases 



SPECIFIC INFECTIOUS DISEASES. 525 

be arrested in this stage, and be cured so that it will not return, or it 
may advance to another group of symptoms, which are represented by 
lesions of the mucous membranes, and sometimes by pseudo-paralysis 
of one or both limbs of a greater or less degree. All these symptoms 
may arise, run their course, and completely disappear, sometimes never 
to return. Again, they may reappear at various times during the indi- 
vidual's life, but they are especially liable to recur during the middle 
period of childhood and at puberty. 

The course of syphilis is so influenced by treatment that the symp- 
toms must necessarily be irregular. When the disease is untreated, as a 
rule, all the symptoms grow worse. The infant becomes more and 
more emaciated, and either it dies in a few weeks of inanition, or the 
disease progresses still further and serious lesions of the various organs, 
such as the lung, liver, spleen, and kidney, may finally produce a fatal 
result. 

Efflorescence. — We can judge to a great degree as to the severity of 
the disease by the type of the efflorescence, and also by the time when 
it occurs after birth. The mildest and most benign form of syphilitic 
efflorescence is represented by macules, the next by papuke, and the next 
by pustulce and bailee. Another form of efflorescence simulating psoriasis 
is one of the more severe manifestations of syphilis, as is also that form 
which is called rupia, where the efflorescence consists of thick layers of 
crusts arranged one above the other, forming a conical mass, the skin at 
the base being somewhat infiltrated. All of these types of the disease have 
been known to be cured. Finally, one will meet at times with a very 
dangerous form of the disease, which is almost uniformly fatal no matter 
what the treatment may be. This is what is called syphilitic pemphigus, 
and is represented by large and numerous bullae. The syphilitic efflores- 
cences, unlike most other lesions of the skin, appear commonly on the 
palms of the hands and the soles of the feet. 

Alopecia. — In addition to these general symptoms there occurs in the 
hereditary form of syphilis the loss of hair which is so common in the 
acquired form of the disease. This alopecia may be caused by any of 
the dermal lesions which occur during the course of the disease, but is 
probably due mostly to the general lack of nutrition in which the skin 
participates with the other organs of the body in syphilis. In certain 
cases the eyebrows and eyelashes are lost, and Barlow believes that the 
former condition is characteristic of the disease, or at least should excite 
a suspicion of its presence. 

Lymph- Nodes. — Enlargement of the lymph-nodes, adenopathy, seems 
to be less marked in hereditary syphilis than in the acquired form. This 
enlargement may be due to reflex irritation from the more severe dermal 
lesions, but in certain cases it is found where no dermal lesion exists. 
The enlarged nodes may be in the inguinal, the axillary, or the cervico- 
maxillary regions. They are distinct, movable, multiple, and non-inflam- 



526 PEDIATRICS. 

matory. The older the child the more likely the glands are to be en- 
larged. 

Nails. — According to Post, the nails are involved quite frequently in 
hereditary syphilis, and more frequently than in the syphilis of the adult. 
The onychia occurs in two forms. In the first form a papule or pustule 
appears on the skin at the side of the nail. This ulcerates and extends 
along the side of the nail, at times involving the matrix and causing the 
loss of the nail. The thick and everted edges of the ulcer, its sloughing 
base and sanious discharge, are somewhat characteristic, and are accom- 
panied by a painful enlargement of the distal phalanx. (For another 
form of onychia, see page 538.) 

Teeth. — The effect of hereditary syphilis on dentition is quite marked. 
The first teeth instead of being cut in the sixth or seventh month may 
not appear until the fourteenth or fifteenth month, and sometimes even 
later. These primary teeth are especially liable to decay early. There 
is nothing sufficiently characteristic to be of diagnostic value in the ap- 
pearance of the teeth of the first dentition. 

Eye. — Hutchinson has observed twenty-three cases of iritis in syphi- 
litic infants. The average age for the beginning of the iritis was five 
and a half months. The oldest was sixteen months at the time of the 
outbreak, the youngest six months. Both eyes were affected in eleven 
cases, and in fifteen cases the effusion of lymph was copious. The 
cornea was affected in a few cases. In seven cases the cure was com- 
plete, in twelve the pupil was partially occluded. Iritis is one of the 
rarest of the symptoms of hereditary syphilis, and at times escapes notice 
on account of the very slight symptoms which usually attend it. The 
diagnosis in these cases is not dependent on the iritis alone, but the 
infants always show other w^ell-marked symptoms of syphilis. There is 
great danger of the disease resulting in blindness if it is left untreated,, 
and mercurial treatment is most efficient in effecting a cure. 

Digestive Organs. — In regard to the digestive disturbances which arise 
in these cases of hereditary syphilis, it is well to remember that they may 
depend upon a syphilitic lesion of the liver, spleen, and pancreas, as welL 
as of the stomach and intestines. It is, therefore, necessary to treat 
these disturbances of the gastro-enteric tract in a different manner from 
what is customary where a local non-syphilitic cause is supposed to be* 
present. In fact, mercurial treatment will produce the best results in 
these cases. 

Hemorrhages. — An affection called syphilis hemorrhagica neonatorum is- 
met with at times. Bumstead and Taylor have reported two cases of 
this kind, and state that the disease is rare, less than twenty cases having 
been noted. The hemorrhages vary in their extent, and may occur in 
either the skin or the mucous membranes. This class of cases is difficult 
to differentiate from the hemorrhagic disease of the new-born which has 
already been described. There is no doubt that syphilis has in a number 



SPECIFIC INFECTIOUS DISEASES. 527 

of cases an etiological significance in the umbilical hemorrhage which 
occurs in the early days of life. Dr. Uracek has reported a series of 
hemorrhages in the different internal organs apparently depending upon 
a syphilitic taint in the infant. 

Nose. — The occlusion of the nares may increase to such a degree that 
the breathing of the infant is seriously interfered with, and, without any 
other syphilitic lesion, it may die from imperfect oxygenation of the air 
which enters its lungs. 

This occlusion of the nares may cause great loss of sleep. We must, 
however, understand that, even where this lesion is not of any great ex- 
tent, syphilitic infants suffer from insomnia. This insomnia is usually 
accompanied by crying, so that it is probable that the restlessness and in- 
somnia are due to pain in the bones, as these symptoms are often present 
where there is no digestive disturbance. In connection with these syphi- 
litic lesions of the nose, flattening of the bridge of the nose is at times a 
noticeable symptom. 

Anus. — There is nothing especial to describe concerning the condylo- 
mata which are found in the anal region and which are rare in compari- 
son with the lesions of the mouth. They begin as rounded papules, which 
sometimes coalesce, and there is more or less infiltration of their edges 
and breaking down of their centres. 

Mouth. — The syphilitic lesions of the mouth are found so commonly, 
and are of so important a character, that an especial description should 
be given of them. There is no syphilitic lesion of the mouth which is 
represented by a characteristic stomatitis. The mucous membrane in the 
course of hereditary syphilis may at any time be in so sensitive a condi- 
tion that the various forms of stomatitis may be engrafted on it, and we 
thus may have different lesions of the lips, tongue, buccal cavity, and 
tonsils, which, while simply representing the lesions of certain non-syphi- 
litic affections, may, by their peculiar grouping in combination with other 
symptoms, represent the hereditary form of syphilis. The lesions most 
commonly appear around the lips and on the mucous membrane lining 
the cheeks. On the lips fissures are exceedingly frequent ; on the upper 
lip they commonly appear on either side of the median lobule, while on 
the lower lip they are usually single and in the median line. The angle 
of the mouth is often the seat of condylomata, and these are frequently 
covered with crusts and at times are deeply ulcerated. A peculiar appear- 
ance is in some cases seen at the commissures of the mouth, caused by 
cutaneous ulcerations, which make it look larger than normal, and at 
times produce a number of lines radiating from the mouth to the cheeks. 
Ulcerations may occur on the tongue, the lips, and the fauces. Forch- 
heimer considers that the fissures which occur in syphilitic infants' mouths 
when they are present, leave no doubt as to the diagnosis, since they are 
infiltrated. The most common place for them to appear is at the corner 
of the mouth. In this place, as a rule, the most striking feature of the 



528 PEDIATRICS. 

fissure is that it is a papule which has been split in or about its middle, 
and that it has an infiltrated edge. The fissures sometimes disappear in 
the mucous membrane, sometimes stop before reaching it, and sometimes 
run into it. The fissures may or may not be covered by a crust, and, 
unlike most syphilitic efflorescences, produce more or less pain when the 
mouth is opened. These fissures are called rhagades. They are charac- 
terized by their persistency and by their lack of tendency to spontaneous 
healing. Ulcers and plaques muqueuses may be found upon the mucous 
membrane of the lips and cheeks and on the sides and under surface of 
the tongue. They are superficial, but cover more space than the fissures. 
The infiltration is not so well marked, but is present to a greater or less 
degree. The most common lesions which are found on the tongue are 
these plaques muqueuses and ulcers. Both have infiltrated edges, but 
the plaque in this situation rises above the level of the tongue, while the 
ulcerations are considerably depressed. They are both characteristic of 
syphilis. Their locality is determined somewhat by the presence of such 
irritants as sharp teeth pressing against a portion of the tongue. The 
secretion of all these lesions of the mouth and lips is highly infec- 
tious. 

Bones. — One of the striking symptoms of this early stage of heredi- 
tary syphilis results from osteochondritis. According to Post, the form 
of lesion is usually that of a tumor at the junction of the diaphysis and 
epiphysis at the distal end of the long bones, although any part of the 
osseous system may be involved. These swellings are difficult to recog- 
nize in fat children. The tumors rise- abruptly from the bones ; they are 
small and globular, and in some cases form a ring at the junction of the 
shaft and epiphysis ; in others the whole epiphysis is enlarged. At times 
only a part of the cartilage is affected, and the external swelling is corre- 
spondingly circumscribed. The lesions appear soon after birth, and their 
development is completed either slowly or rapidly. The termination 
varies widely. The swelling may be absorbed under appropriate treat- 
ment, or suppuration may take place and the skin break down ; the dis- 
ease may end in the separation and destruction of the epiphysis. The 
result upon the final growth of the bone varies, of course, with the 
severity of the local disease. When the morbid process is arrested before 
the destruction of either cartilage or epiphysis, there is no deformity, but 
the destruction of cartilage puts an end to growth at that point, and 
a more or less shortened and useless limb results. When the disease 
takes such a course as to separate the epiphysis while the integuments 
remain sound, the limb becomes useless for a time and appears to be 
paralyzed. The disease was first fully described by Parrot, and is known 
as Parrot's disease, or syphilitic pseudo-paralysis of the new-born. The 
joints in immediate connection with the diseased bones are sometimes in- 
volved. There may be simply an effusion, but, where the bone is de- 
stroyed, serious disorganization of the joint must follow. The pain and 



SPECIFIC INFECTIOUS DISEASES. 529 

sensitiveness in these cases of pseudo-paralysis are probably caused by a 
low grade of periostitis. 

The bones of the fingers and of the toes present at times the pecu- 
liar lesion which is known as dactylitis syphilitica. The phalanx may be 
enlarged to two or three times its natural size, giving the fingers a pyri- 
form shape. One or several fingers or toes may be involved, and some- 
times the metacarpal bones are diseased. The proximal phalanx is more 
frequently affected than the distal phalanx. In the early stages the integu- 
ment is unchanged ; later, the overlying parts become involved and 
abscesses form. If the case is submitted to early treatment the deformity 
usually subsides, but if untreated the disease may result in permanent 
deformity and uselessness. Dactylitis, however, is not characteristic of 
syphilis alone, as it occurs also as a result of tubercular disease of the 
bone. 

One of the more uncommon symptoms of hereditary syphilis is cranio- 
tabes, but in rare cases it may be found. These softened spots, nearly 
circular in form and about 1.2 cm. (J inch), more or less, in diameter, 
may be recognized by the finger during life. Formerly craniotabes was 
considered to be exclusively a symptom of rhachitis. It is found 
especially in the occiput. It is present in rhachitis where no trace of 
syphilis can be discovered, but it seems to be most common in cases in 
which there is a distinct syphilitic taint. Out of one hundred cases of 
craniotabes collected by Drs. Barlow and Lees, in forty-seven there was 
satisfactory proof of syphilis. 

Diagnosis. — The diagnosis of hereditary syphilis in its more advanced 
forms, such as has just been descrmed, is not difficult, as no other disease 
represents such serious lesions of the skin with such a combination of 
general symptoms and lesions of the mucous membranes. 

The milder forms of the disease are frequently mistaken for other 
diseases of the skin, such as papular erythema, which simulate the syphi- 
litic lesions but which are of a benign character. 

Occlusion of the nares caused by swelling of the Schneiderian mem- 
brane, if persistent during the early weeks and months of life without rise 
of temperature, should always make us suspicious of the presence of 
hereditary syphilis, for a syphilitic efflorescence is often so slight and eva- 
nescent as to be frequently overlooked. 

Marked improvement following the administration of mercury is also 
usually considered of diagnostic value, and, although not by any means 
conclusive, is at least significant. 

Periostitis, especially of the lower end of the humerus or the anterior 
border of the tibia, is met with in children. It should make us suspicious 
that syphilis is causing this condition, especially if there is periostitis of a 
number of bones at once. 

A great deal has been written and much discussion has taken place 
regarding the relationship between syphilis and rhachitis. The two dis- 

34 



530 PEDIATRICS. 

eases are so distinctly separated that it seems scarcely necessary to dwell, 
except very briefly, on the differential diagnosis between them. Rha- 
chitis is so largely dependent in its osseous changes on a profound dis- 
turbance of nutrition that it can fairly be said to result from any disease 
which from its debilitating nature may interfere with the nutrition of the 
bones. In this way individuals whose nutrition has been seriously af- 
fected by hereditary syphilitis may develop rhachitis. 

In regard to the actual lesions of the bones present in syphilis and 
rhachitis, there seems to be a concurrence of opinion that the pathologi- 
cal conditions are quite different. Thus, syphilitic bones very rarely 
present the spongy tissue peculiar to rhachitis, and rhachitic bones never 
show the osteophytes of syphilis. 

Prognosis. — The prognosis in any case of hereditary syphilis is a se- 
rious one. In addition to the results which we are likely to have from 
the syphilis of the parents being early or late in regard to the impregna- 
tion, and from their having been thoroughly treated or not, there are 
certain facts to be remembered concerning the infant itself. 

The prognosis is grave inversely to the number of weeks after birth 
when the disease first shows itself. The milder forms of the efflorescence 
justify us in giving a better prognosis than the more severe ones. In 
addition to these conditions which render the prognosis more favorable 
are the possibility of the infant being fed with good breast-milk or with a 
carefully prepared substitute food, and good hygienic surroundings. 

The cases in which the spleen is much enlarged are evidently so pro- 
foundly affected by the secondary anaemia by which the enlargement is 
caused that the prognosis is almost invariably bad, and the degree of 
splenic enlargement may almost be taken as an index of the severity of 
the disease. 

The opinion which we give to the parents should, however, always 
be very guarded, as, even though the disease may for the time apparently 
be entirely cured, it is always liable to appear again in later childhood 
and at puberty. When the disease is amenable to treatment these sec- 
ondary symptoms almost always disappear by the second year, and in 
quite a large number of cases, where proper treatment has been thor- 
oughly carried out, the infant recovers entirely and is as well and strong 
as though it had never had syphilis. In another set of cases, however, 
although the disease is apparently eradicated, in later years it is found to 
have left its marks in disturbances of the different functions and in the 
general lack of vigor of the various tissues. 

Treatment. — The treatment of hereditary syphilis is first to adapt at 
once as nourishing a food as is possible to the infant's digestion. A healthy 
mother with plenty of good breast-milk will, as a rule, provide the best 
food for her infant. 

If the mother's nutrition is reduced by syphilis or by any other chronic 
disease, the infant should be fed on a properly adjusted substitute food, 



SPECIFIC INFECTIOUS DISEASES. 531 

while the general hygiene, such as fresh air, sunlight, and warmth, should 
be carefully regulated. A wet-nurse should not be employed unless she 
has herself had syphilis, in which case the same rules will apply to her 
nursing as to that of the syphilitic mother. 

It should be remembered that the secretions from a syphilitic infant's 
mouth are very infectious, whether the disease is of the hereditary or 
of the acquired form. If, therefore, the mother is not syphilitic and the 
infant has acquired in any way a syphilitic lesion, the nursing must be 
discontinued and the infant fed on a substitute food. 

The only drug- which can be depended upon in the treatment of the 
early lesions of hereditary syphilis is mercury. This drug naturally would 
be employed from our experience with it in acquired syphilis, where 
it is more valuable in the early stage of the disease than at any other 
period. In like manner iodide of potash is of little use in the early 
stages of hereditary syphilis, while it becomes useful in the retarded form, 
which corresponds to the later stage of acquired syphilis. 

It is important carefully to adapt the form, of mercury which is given 
to the syphilitic infant according to its special idiosyncrasy for the drug, 
and also to regulate the means of its administration according to the ne- 
cessity of having it act quickly, as is indicated in the more severe forms 
of the disease, and according to the sensitiveness of the individual's stomach 
or skin. Thus, mercury may be administered either through the mouth 
or through the skin. In the latter case it may be applied directly in the 
form of liquid or ointment or by means of subcutaneous injections. The 
last method should be used in very urgent cases only, for the tissues and 
skin of the syphilitic infant are especially liable to be irritated to such an 
extent that sloughing may take place, and the tissues under these circum- 
stances are readily destroyed. When used, it should be in the form ot 
corrosive sublimate. 

The corrosive sublimate should never be given subcutaneously in 
larger doses than 0.0006 gramme ( T ^ grain). Where the mercury is to 
be applied directly to the skin it may be in the form of corrosive subli- 
mate baths, 0.3 to 0.6 gramme (5 to 10 grains) to each bath once daily, 
but practically it is found better to introduce it into the system by means 
of an ointment. This ointment may be the official mercurial ointment, 
either in full strength or diluted with some simple ointment, and this 
may be applied by means of inunction, as is the custom in the acquired 
syphilis of adults. After the infant's skin has been thoroughly washed, a 
small portion of the ointment should be applied to its back and rubbed 
carefully and gently into the skin for ten minutes. On the next clay the 
same procedure can be carried out on the front of the chest ; on the third 
day in the axillary regions ; and on the following days respectively on the 
outer surfaces of the arms and thighs. I have found that the most 
practical way of applying inunctions to these infants is, after having 
thoroughly washed the abdomen, to spread the ointment thickly on a 



532 PEDIATRICS. 

piece of thin soft flannel cut so as to reach from the ensiform cartilage to 
the pubes and to extend around the entire abdomen. This ointment is 
made in the following way : 

Prescription 78. 
Metric. Apothecary. 

Gramma. 
R Unguenti oleati hydrargyri, R Unguenti dleati hydrargyri, 

Unguenti lanolini aa 60(00 Unguenti lanolini aa I ii. 

M. M. 

The band should be allowed to remain in place for forty-eight hours. 
It should then be removed, and, after the skin has been thoroughly washed 
with warm water and soap and dried with a soft towel, the flannel should 
again be spread with the ointment and reapplied. 

In giving mercury by the mouth I am in the habit of using the official 
hydrargyrum cum creta. I usually begin with 0.06 gramme (1 grain) of 
the drug, administered three times in the twenty-four hours. Within a 
few days the dose is increased to four times in the twenty-four hours, 
and if no unfavorable symptoms appear it is again raised to 0.12 gramme 
(2 grains) three or four times in the -twenty-four hours. 

The unfavorable symptoms which have just been referred to as pos- 
sibly being caused by the drug are represented by diarrhoea. We must 
remember that the infants whom we are treating for hereditary syphilis 
are so young that the salivary secretion has been very slightly developed, 
and that therefore Ave naturally do not salivate an infant of this age so 
readily as we would a child or an adult. We must not, however, think 
that we can be guided as to the amount of mercury we are introducing 
into the infant's stomach by salivation, which is usually relied upon to 
indicate the physiological action of mercury. I have found it a safe rule 
to continue with the mercury until diarrhoea is caused, when the drug 
can be reduced in quantity, or even be omitted for a few days. When 
the intestine has become less sensitive we can again begin with a smaller 
dose, and one which by experiment has been shown not to cause diar- 
rhoea in the especial infant. 

Other forms of mercury, such as calomel in doses of 0.006 gramme 
( T V grain) three or four times daily, may be given by the mouth in these 
cases. 

These various forms of mercury should be tried when for any reason 
one of them is found not to suit the case. 

For the treatment of the fissures which occur around the lips and the 
lesions of the mouth, as well as those which occur at the anal orifice, I 
am in the habit of using a simple powder of calomel, which is dusted on 
the part affected. The mouth should be carefully cleansed several times 
during the day and a wash of chlorate of potash used at least twice a day. 
In some cases, although rarely, nitrate of silver is needed as an application 
to the ulcers when they are intractable. When there are crusts around 
the lips and in the neighborhood of the fissures, or where anal condylo- 



SPECIFIC INFECTIOUS DISEASES. 533 

mata are present, the mercurial ointment just spoken of is of much 
benefit. The crusts should be carefully removed from the nose and this 
same ointment gently applied to the lesions. The application of this oint- 
ment to the abdomen is at times followed by an eczematous irritation of 
the skin of the abdomen. Under these circumstances any simple emol- 
lient should be applied in place of the mercurial for a few days until the 
skin has recovered, and the mercury can then be further diluted with 
lanoline or some simple ointment and reapplied, thus finally adjusting the 
strength of the mercurial to the vulnerability of the infant's skin. 

In addition to the mercurial treatment, tonics in some form, especially 
iron, are at times required. It is usually in the later stages of the disease 
that they are indicated, and in cases in which the persistence of the 
splenic enlargement shows the presence of profound secondary aneemia. 

After all the symptoms of syphilis have disappeared and the infant is 
entirely well, the mercurial treatment should be continued for some 
months, and also later during the first three or four years of its life, at 
intervals of three or four months, even when there is no return of the 
syphilitic symptoms. It should likewise be given at intervals during 
the period of the second dentition, and again at puberty. This treat- 
ment is especially important whether the infant appears to be in good 
health or not, as it tends to prevent a recurrence of the disease, and 
we should remember that a recurrence often proves very intractable to 
treatment. 

The following cases illustrate the different phases of hereditary syphilis 
and the different conditions which are liable to be met with in this disease. 

The first infant was three weeks old. Its mother looked well and strong, denied 
having had any miscarriages or disease of any kind, and asserted that the father was 
also healthy. Both of these statements were probably untrue, but an excellent oppor- 
tunity for making a diagnosis simply by inspection and by a physical examination was 
given. 

At birth the infant was puny and atrophic. It soon began to have occlusion of the 
nares. When one week old, an efflorescence of papules appeared on its arms, legs, and 
feet, with pustules on the palms of the hands and the soles of the feet. It did not 
vomit. The faecal movements were of a good color and fairly well digested. The heart 
and lungs were normal. The splenic area of dulness was slightly increased, but the 
spleen could not be felt. There were marked fissures at the angles of the mouth, a 
muco-purulent discharge from the nose, and crusts forming on the eyebrows. The 
mouth and throat showed nothing beyond a pronounced erythema. There were papules 
and pustules on the body, and a squamous as well as a pustular efflorescence on the 
palms of the hands and the soles of the feet. There were maculae on the buttocks. 
The anus showed nothing abnormal. The temperature was normal. The infant looked 
fairly well nourished. 

There could be no question about the diagnosis in a case like this, and the state- 
ments of the mother regarding herself and her husband were entirely ignored, for by 
simple inspection it was clear that it was a case of hereditary syphilis. 

The next infant was six months old. The mother, a healthy-looking woman with 
plenty of breast-milk, nursed the infant. She had had one miscarriage, in the third 
month, and this was her first child. The father denied having had any venereal disease. 



534 PEDIATRICS. 

At birth the infant was rather atrophied and had a general papular efflorescence 
all over it, and later a squamous efflorescence on the palms of the hands and the soles 
of the feet. It always had marked occlusion of the nares (snuffles). The infant was 
immediately placed under treatment, and at six months looked well nourished. It Was 
a case of hereditary syphilis, and showed the beneficial results of good breast-milk and 
mercury, for it was very large for its age and was fat and strong-looking. It had, 
however, certain lesions of the bones which were the result of the syphilitic manifes- 
tations which it presented at birth. One of these lesions was represented in the 
marked prominences on either side of the frontal bone, with a somewhat depressed 
sulcus between them. 

The first phalanx of the left little finger and that of the left third finger were 
swollen and somewhat reddened, and the tissues had a tendency to break down. This 
is the condition which has already been described as syphilitic dactylitis. Cases of 
tuberculosis of the bone often simulate this condition, and, in fact, so nearly approach 
it in appearance that the two diseases cannot be distinguished by simple inspection. 
The diagnosis must be made by considering the other symptoms. 

The syphilitic infant is described essentially as atrophic ; this is, as a rule, the case 
only when it is deprived of good breast-milk or of a properly proportioned substitute 
food, the atrophy being usually a fault in diet, provided that the intra-uterine nutrition 
has been good. 

Syphilis is so prolific a source of miscarriage that a history of miscar- 
riage in the mother justifies us in looking with suspicion on a doubtful 
lesion of the skin in her infant. A woman may have a number of mis- 
carriages caused by syphilis, and may then, if she has been treated with 
mercury, give birth to a living syphilitic infant, or to one that is healthy. 
These facts are important for us to remember when we are considering 
the prognosis in a case of hereditary syphilis. 

The next infant illustrates one of the many unusual forms of syphilis 
which may manifest itself in infancy. 

A male, four months old, was brought to my clinic with syphilis of a rather aggra- 
vated type, and among other lesions with condylomata at the anal orifice. 

It had a general papular efflorescence on the face, body, and limbs, including the 
palms of the hands and the soles of the feet. The left arm hung helpless by its side. 
The left leg was also somewhat affected. On examining the arm there was found a 
small, hard, painful, circumscribed swelling at the lower end of the humerus. No crep- 
itation was detected. 

The condition was one of the osseous lesions of syphilis, an osteochondritis ac- 
companied by periostitis, which caused so much pain on movement as to disable the 
limbs and simulate both paralysis and fracture. Mercury was given and the infant 
recovered. 

The next case is of remarkable interest, owing to the form and appearance of the 
efflorescence, which, although unusual, is so characteristic that it could represent no 
other disease than syphilis. 

The infant was six weeks old. The mother stated that she had been married 
about three years, had had two children, and had had no miscarriages. She said that 
the father was well and strong, and that neither of them had had any efflorescence 
on their skin. The older infant was fourteen months old, and was healthy. The 
younger infant was being nursed by its mother. At birth it was apparently healthy 
and well nourished. Its skin was clear, its body fat, and there was no occlusion of 
the nares. This condition continued until it was eight days old. It then began to 
have occlusion of the nares (snuffles), a slightly hoarse voice, and an efflorescence on 



SPECIFIC INFECTIOUS DISEASES. 



535 



various parts of the body and limbs. This efflorescence consisted mostly of maculae, 
many of which were circumscribed by healthy skin. They varied in size from 0.6 to 
1.25 cm. (I to \ inch). 

Plate X., facing page 610, shows a number of lesions represented in this case. 

In addition to the maculae, which varied from a delicate pink to a yellowish-white 
color, there was a pustule on the outer side of the leg just below the knee. On the 
inner edge and almost on the back of the foot were the remains of a bleb which had 
broken down and had been emptied of its contents. There was also on the inner side 
ofithe foot, nearer to the heel, a small ulcer. The entire skin of the heel was reddened 
and had a shining appearance. The erythematous lesions in places on the leg were 
surrounded by normal skin, presenting a mottled appearance, and there were white 
spots on the skin. These latter, however, were caused merely by the peculiar distri- 
bution of the syphilitic maculae. 

In addition to these lesions on the leg there were a few ulcers on the buttocks, 
and in addition to the maculae on the soles of the feet there were some on the palms 
of the hands. A few scales showing a squamous condition could be seen on the left 
leg, but this lesion was not a prominent one. 

The eyes were not affected. There were a few fissures about the mouth, but no 
lesions of the buccal mucous membrane, and there were no gummata around the anus. 

The treatment of this case was by inunction with the oleate of mercury ointment 
and by the administration of hydrargyrum cum creta. 

Fig. 120 represents the lesions of syphilis on the soles of the feet in a male. The 
lesions consisted of a number of bullae, some of which had burst, and the tissue 




Syphilitic macul 



soles of the feet. Male, 2% months old. 



beneath having broken down, ulcerations were formed. There were also a few papules, 
some smaller bullae, and some pigmented areas. 

This same case had the "waxen" pallor of the skin, so characteristic of the 
higher grades of grave anaemias. There was moderate enlargement of the liver, which 
on palpation was found to be hard and somewhat tender. The inguinal glands were 
slightly enlarged. The post-aural glands were enlarged. The spleen was much 
enlarged and extended, as indicated in Fig 121 by the black line, from the fifth rib 
to the left inguinal region. It was hard, but was not tender. There were no other 
glandular enlargements. The examination of the blood was as follows : 



Nov. 17. 

Erythrocytes 3.387,000 

Haemoglobin 47 per cent. 

Leucocytes 20,000 



Nov. 20. 
3,300.000 
45 per cent. 
20,000 



536 



PEDIATRICS. 



There was a considerable variation in the size of the erythrocytes, which were pale 
in color. There was poikilocytosis in a moderate degree ; there were also some micro- 
cytes and megalocytes. The mononuclear elements predominated (about three-quar- 
ters). The eosinophiles were not numerous. 

Pig. 121. 




Male, 2% months old. 



Congenital syphilis. Grave secondary ansemia. 
and enlarged spleen marked in black. 



Lower border of ribs, fifth rib, 



Late Manifestations of Hereditary Syphilis. — Symptoms. — The mani- 
festations of hereditary syphilis which appear at birth usually develop in 
the first three or four months of the infant's life. In certain cases of 
syphilis which are without doubt of the hereditary form, either no symp- 
toms whatever are noticed in the early years of life, or they are so slight, 
or so lacking in the characteristics of syphilis, that it is sometimes impossi- 
ble to recognize them as syphilitic lesions. The lesions of this late heredi- 
tary form correspond to the tertiary lesions of the acquired form. They 
appear in different periods of childhood or at puberty. These periods 
correspond to the time when a fresh outbreak of an attack of syphilis 
which has occurred in the early months of life is apt to take place. This 
is significant as leading us to suspect that the early symptoms of the 
disease have been overlooked rather than to believe that they did not 
occur. 

Bones. — The lesions of the bones hold a prominent place in these later 
manifestations of hereditary syphilis. These lesions may be in the form 
of a periostitis, or an actual necrosis of the bone may take place either in 
connection with a dactylitis or with a simple lesion of the osseous tissue 
in any of the bones. 

As these later forms of hereditary syphilis merely represent the same 
conditions which are met with in tertiary acquired syphilis, we should expect 
the most varied lesions. In this late form of hereditary syphilis the bones 
of the nose are frequently involved, and a flattening of the bridge of the 
nose is not uncommon. The cranial bones show certain alterations which 
at times are quite characteristic. The frontal bone may present a promi- 
nence on either side, which, with a depression more or less deep between 



SPECIFIC INFECTIOUS DISEASES. 



537 



the prominences, causes such a peculiar conformation of the head as to 
be almost characteristic of syphilis. This is well represented in Fig. 124, 
on page 541. In addition to these frontal prominences, at times there is 
a prominence of the centre of the frontal bone, which, with the apparent 
flattening on either side, causes a peculiar shape simulating the keel of a 
ship. Sometimes protuberances similar to those which have been de- 
scribed of the frontal bone may appear on the parietal bones. When they 
are bilateral the sagittal suture appears as a depressed sulcus between 
them, and this deformity of the skull, from its resemblance to the shape 
of the nates, has been designated by Parrot as the natiform skull. 

These tuberosities on the skull may also appear upon the long bones, 
either in the diaphysis or in the epiphysis. When the tibia is affected 
there is often so marked an increase in parts of the shaft of the bone, 
especially its middle third, that, as the enlargement is chiefly in the ante- 
rior portion, the swelling when prominent gives an appearance of curva- 
ture to the bone. This is, however, only a seeming curvature, as the 
posterior portion of the bone is not affected. 

Mental Development. — An interference with the growth of children 
who are affected by these various osseous lesions of syphilis is not un- 
common. There is frequently a lack of development, which shows itself 
usually in a failure of the individual to attain the ordinary height. The 
mental development is retarded, the children often appearing to be a 
number of years younger than they really are. This condition Fournier 
has designated as infantilism. 

Teeth. — The first set of teeth in infants with hereditary syphilis have 
nothing characteristic about them ; they shoAv a lack of nutrition, a con- 
dition which may arise from many other morbid processes. 

The second set of teeth, however, present certain characteristics. 
These characteristics are shown especially in the two middle upper in- 
cisors, in which the cutting edge of the 
tooth is worn away, leaving a convex sur- 
face with the convexity upward. The 
teeth are also apt to be somewhat far 
apart, and, as the child grows older, to 
assume a peg shape. The especial char- 
acteristics of syphilitic teeth were first 
described by Hutchinson. This peculiar 
shape of the teeth is not always present 
in syphilis, but when it appears it is cer- 
tainly very suggestive of the disease. As 

was pointed out by Coleman, the dentist who examined Hutchinson's 
cases, in nearly every one of them there was a deficiency in the superior 
alveolar arch at the anterior portion, so great in some cases that when 
the jaws were closed the upper and the lower incisiors did not come 
together. 



Fig. 122. 




Syphilitic teeth of the second dentition. 



538 PEDIATRICS. 

Fig. 122 represents twelve syphilitic teeth of the second dentition. 
They are all more or less disorganized in a way which might occur from 
any cause which would interfere with the normal development of the teeth 
and cause their early decay. The middle two and the left lateral upper 
incisors show the notched and somewhat peg-shaped condition which is 
supposed to be characteristic of syphilis. 

Nails. — The onychia which occurs as one of the earlier manifestations 
of hereditary syphilis has already been described. In the late form of 
syphilis another form of onychia is met with, characterized, according to 
Post, by a swelling at the base or the side of the nail, which becomes 
thickened, fissured, and brittle, with more or less deformity of the 
phalanx. 

Eye. — In the late form of syphilis a peculiar inflammation of the 
cornea at times appears. It usually begins with a cloudiness of the sub- 
stance of the cornea, with ciliary congestion. The entire cornea in this 
way becomes clouded. The affection is not accompanied usually by pain, 
and does not show any special congestion of the conjunctivae. Hutchin- 
son says that it is always symmetrical, although at first it is apt to begin 
with one eye and later to attack the other. The interval between the 
two attacks may extend over several years. This disease is called inter- 
stitial keratitis, and may for a few weeks seriously interfere with the sight. 
It usually disappears under treatment without leaving any trace of the 
disease behind it. On the other hand, opacities are sometimes left which 
interfere with vision. The total duration of the disease varies from six 
to eighteen months. Interstitial keratitis, according to Post, occurs most 
frequently in female subjects, and is most common between the ages of 
ten and fifteen, although it may occur much earlier, and, according to 
Fournier, may even be met with at birth. Complications may arise in 
the shape of iritis, choroiditis, and retinitis. 

Ear. — Disturbances of hearing may occur from a number of causes, 
especially from those secondary to diseases of the pharynx. An especial 
form of deafness, however, without any special lesions to explain it, occurs 
in the syphilis of childhood, is usually intractable to treatment, and per- 
sists into later life. Extensive ulcerations produced by syphilis may occur 
in the nose and pharynx at any time during childhood. 

Nervous System. — Syphilis of the nervous system may be congenital 
or acquired, involving either the brain or cord. It is very rare in children. 
It may occur as a diffuse inflammation of the meninges^ as localized 
gummata, or as an endarteritis. Syphilitic meningitis and endarteritis 
present essentially the same symptoms as in adults. Gummata of. the 
brain or cord present no symptoms in themselves to distinguish them 
from other cerebral tumors (see page 978). The lesions in the cord 
are, however, apt to be widely distributed, involving the cervical, dorsal, 
and lumbar regions, with preservation of some of the functions and 
complete loss of others. The rapid diminution of some symptoms and 



SPECIFIC INFECTIOUS DISEASES. 539 

the persistence of others are characteristic. The presence of syphilis 
elsewhere and the marked improvement under antisyphilitic treatment 
are important points in the diagnosis. Syphilitic endarteritis and multiple 
gummata of the base have been observed in infants as early as fifteen 
months. 

Treatment. — The treatment of the lesions which usually occur in the 
retarded form of syphilis is essentially with iodide of potash, either alone 
or in combination with some mercurial. The iodide of potash should be 
given at first in doses of 0.12 or 0.18 gramme (2 or 3 grains), and this 
dose should be gradually increased to 0.36 or 0.6 gramme (6 or 10 grains), 
or even more, as children often tolerate this drug remarkably well, and 
large doses are usually indicated. 

When iodide of potash is given in combination with mercury, it is 
well to begin with corrosive sublimate in doses of 0.0006 gramme (y-J-g- 
grain) and gradually to increase the dose. Corrosive sublimate is, how- 
ever, so apt to cause disturbance of digestion that I prefer to treat these 
cases by giving the iodide of potash uncombined with any other drug, by 
the mouth, and by applying the mercurial ointment to the skin. 

The treatment of these later manifestations of syphilis must often be 
continued for long periods. 

The following case illustrates the retarded form of syphilis, and shows 
the importance of carefully reviewing the previous history not only of the 
child, but also of its parents. 

The child was a girl, thirteen years of age. The mother had had no other children 
nor any miscarriages. She had always been well, and had never shown any manifesta- 
tions of syphilis. 

The father, so far as could be ascertained, until recently had always been well and 
strong, and had shown no signs of syphilis. About one year previous he began to have 
cerebral symptoms, which rapidly increased, were accompanied by paralysis, and were 
undoubtedly of syphilitic origin. 

I was first called to see this child when she was suffering from a mild attack of 
appendicitis, which did not come to operation. At that time I noticed a peculiar con- 
formation of the upper incisors, which made me at once suspect a case of hereditary 
syphilis. On further inquiry I learned that she had been treated some years earlier 
by an oculist for keratitis. The upper incisors were abnormally far apart and stunted 
in their growth. They were notched, as was also the left lateral incisor, which was 
peg-shaped and by its clearly cut notch represented more nearly than the others the 
characteristic syphilitic teeth. The right upper lateral incisor had a peculiar shape, the 
crown of the tooth coming down almost to a point. The other teeth were in many 
places deprived of their dentine, and were in various stages of disorganization. 

On recovering from the appendicitis the child remained in a weak condition during 
the following year, looked sallow, and had continual headaches, which did not improve 
under the usual remedies. Treatment with iodide of potash was not only followed by 
the disappearance of the headaches, but also resulted in a healthy appearance of the 
child, who became perfectly well. 

The following case is an illustration of the various tertiary lesions of 
syphilis. 



540 



PEDIATRICS. 



A girl, three and one-half years old, had certain lesions on the face, arms, hands, 
and feet, which were the result of congenital syphilis. When this child was born she 
was apparently healthy. When she was three months old she was noticed to have 
occlusion of the nares, and at that time she had an attack of bronchitis lasting for three 
weeks. It was said that no efflorescence was ever noticed on her skin. When she was 
seven months old her hands began to swell, and at fourteen months the tissues around 
the metacarpal bones of the little fingers of both hands became reddened and ulcerated 
and the fingers assumed the pyriform shape characteristic of syphilitic dactylitis. 

Fig. 123. 




Late manifestations of syphilis. Female, 3% years old. 

When the child was about sixteen months old the feet began to swell, and in 
certain parts, especially the metatarsal bones of the right foot, the skin became red- 
dened. When the child was three years old pieces of dead bone began to come away 
from the hands, and this continued for some time. At the same age, swellings began 
to appear over the upper maxillary bones, and an extensive reddened and swollen 
condition of the tissues existed under the right eye. The fontanelles were closed. 
There were evidently a periostitis and an osteochondritis of the right arm, and there 
was also an enlargement of the left ankle, accompanied by ulceration on the outer side 
of the malleolus. 

The child was treated with the combination of mercury and iodide of potash shown 
in the following prescription : 



SPECIFIC INFECTIOUS DISEASES. 



541 



Prescription 79. 



Metric. 

Gramma. 

R Hydrarg. chloridi corrosivi 0:03 

Potassii iodidi 3 75 

Aq. destil 60!00 

M. 



Apothecary. 



R Hydrarg. chloridi corrosivi gr. ss 

Potassii iodidi 3 i ; 

Aq. destil ^ ii. 

M. 



S. — 2 c.c. (£ drachm) 3 or 4 times in 24 hours. 

While it was taking this medicine all its symptoms ahated, it seemed better and 
brighter, and the lesions showed a tendency to heal. Whenever the medicine was 
omitted all the previous symptoms returned. 

The following case illustrates, among other interesting points, this same 
lesion of the bones. 

The boy was six years old. He was rather pale, and had a somewhat peculiar 
frontal development, which well illustrates one form of syphilitic head. 

There was a slight depression of the bridge of the nose and the bulging of the fore- 
head on either side just above the orbital ridges. These prominences were accentuated 

Fig. 124. 




IK 



Hereditary syphilis. Male, 6 years old. Abnormal prominences of frontal bone. 

by the deep sulcus between them, extending from the depressed nasal bones upward 
almost to the margin of the hair. This condition represents the typical syphilitic head. 

The boy was in fair health, and had nothing abnormal about him on careful physi- 
cal examination. His mother brought him to the clinic to receive a course of treatment 
for a few months in order to prevent a recurrence of his infantile syphilis. 

The boy had been treated at the Children's Hospital when he was six weeks old. 
The mother had been well and strong, and had never had any other children nor any 
miscarriages. The father had had a primary syphilitic lesion one year previous to the 
birth of the child, which was followed by secondary manifestations. The mother had 
plenty of good breast-milk, and nursed her infant until he was nineteen months old. 
He was never atrophic, and although pale was apparently well nourished. At birth 



542 PEDIATRICS. 

he showed a bullous efflorescence of medium grade. During the early weeks of his 
life he did not receive any medical treatment, although he had a general efflorescence 
of macules, pustules, and bullae. At about the fifth week he lost the use of his left 
arm. When seen at the sixth week he showed a number of lesions besides those 
described, and it was doubtful if he would live. These lesions consisted of fissures at 
the corners of the mouth, mucous patches in the mouth, condylomata of the anus, and 
occluded nares. There was not at that time the peculiarly formed head which is now 
present. The left arm was helpless and was supposed to be broken ; in fact, there was 
some crepitation, and probably there was a slight separation of the epiphysis of the 
distal end of the humerus. There seemed to be considerable pain in the arm, which 
made the infant restless and fretful. Insomnia was a prominent symptom. The arm 
was put in a light splint, and the oleate of mercury ointment (Prescription 78, page 
532) was ordered. 

The infant was not seen for a week. When he was brought back to the hospital 
the right arm was found to be helpless, and the mother stated that the ointment had 
been discontinued, as it caused excoriation of the skin. The ointment was then re- 
duced one-half with lanoline, and hydrargyrum cum creta was given three times daily 
in doses of 0.06 gramme (1 grain). 

In three days he was much better, the paralysis soon disappeared, and nothing 
abnormal was detected about the arms. The hydrargyrum cum creta was increased 
to 0.24 gramme (4 grains), but as this caused diarrhoea the dose in a few days had 
to be reduced to 0.18 gramme (3 grains). In the course of the next month the nasal 
symptoms and the efflorescence had disappeared, and the infant seemed perfectly well. 

Six months later he was brought back to the hospital with a return of the condylo- 
mata and a slight papular efflorescence. The same treatment as before was carried out. 
The syphilitic manifestations disappeared, and did not return. 

He was kept under observation and treated from time to time for three or four 
years. The first teeth were cut at nine months, and were in fair condition. 

THE EXANTHEMATA. 

In contradistinction to the various diseases of the skin which derma- 
tologists are accustomed to designate as exanthems of local origin are 
certain acute, specific, infectious diseases which are called the exanthe- 
mata. This group of infectious diseases is of especial interest in con- 
nection with children, as it is among children that they most frequently 
occur. They can, however, attack individuals of any age. Although 
none of these diseases are entirely self-protective, yet the instances in 
which they develop in an individual more than once are rare. 

The exanthemata comprise five diseases, — scarlet fever, measles, rubella, 
varicella (chicken-pox), and variola (small-pox). Each of these diseases is 
characterized by certain conditions common to all. Besides being infec- 
tious, each disease runs a definite course and is self-limited, facts which 
should be remembered when we are studying its diagnosis and treatment. 

The course of these exanthemata from the time when the infection 
takes place up to the appearance of their later manifestations may be 
divided into distinct stages. In the first of these certain micro-organisms 
are supposed to enter the system, and, so iar as external appearances 
and general symptoms are concerned, to remain dormant for a time, 
constituting what is called the stage of incubation. This stage of incuba- 



SPECIFIC INFECTIOUS DISEASES. 543 

tion is followed by certain general symptoms resulting from the supposed 
development of the special organisms and constituting the prodromal stage. 
These prodromal symptoms are, after intervals varying according to the 
special disease, followed by an efflorescence on the skin, which marks the 
third stage of the disease, called the stage of efflorescence. The efflores- 
cence in its turn is followed by what is called the stage of desquamation, 
this desquamation being more or less pronounced in proportion to the 
intensity of the lesions of the skin which have occurred during the stage 
of efflorescence. 

Although in a large number of cases the diagnosis of these diseases 
can be determined by the appearance of the efflorescence and its location, 
yet instances occur not infrequently in which the efflorescence is very 
misleading. We should, therefore, be familiar with the characteristics of 
the other stages, for it is by carefully considering the pictures which they 
present to us as a whole that we are enabled to make a correct differen- 
tial diagnosis of the especial case. Thus, a papular efflorescence, although 
significant in most cases of measles, may also be present in other members 
of the group, while an erythema closely resembling scarlet fever may 
occur in variola, measles, or rubella. 

SCARLET FEVER. 

Scarlet fever is an acute infectious disease, characterized by a short 
incubation, short prodromal stage, erythematous efflorescence, pronounced 
desquamation, and long course. The micro-organism which produces it 
has not yet been determined. With the exception of variola, it is the 
most dangerous of the group, and is therefore the most important of all 
the exanthemata. 

The complications of scarlet fever are so much more serious and its 
sequelae so much more common and grave than those of varicella and 
measles, that its immediate diagnosis and prompt treatment are of vital 
necessity in every community where numbers of children are liable to be 
attacked by the disease. 

Etiology. — Scarlet fever is the most irregular of all the exanthemata 
in its virulence and in the manifestations which it presents in different 
individuals. It is usually epidemic, returning to the same localities after 
a period of years. It is at times sporadic, and is commonly endemic in 
large cities. The epidemics of scarlet fever vary in severity, so that we 
cannot ascribe the virulence of the disease in certain years to individual 
susceptibility. The sporadic cases may be of the most malignant or of 
the mildest type. A mild case may give rise to a malignant case in 
another child, and a malignant case may give rise to a mild one. The 
epidemics of scarlet fever spread slowly, in contradistinction to those of 
measles, which spread rapidly. Scarlet fever may occur more than once 
in the same individual, but this is rare. Instances have occurred in 
which a child has had scarlet fever, and, on returning after several weeks 



544 PEDIATRICS. 

to the same room, even after it had been disinfected, has again con- 
tracted the disease in its typical form. The source and identity of the 
contagium have not been definitely determined. The bacterial infection 
is secondary, and is mostly from the streptococcus pyogenes. The skin 
appears to be the chief vehicle of transmission. It has, however, been 
shown that the discharge from the nose and throat, both in the early 
stages of the disease and when they are prolonged even after the stage 
of desquamation, may be a source of infection. The contagium has a 
great tenacity for clothing and other articles, and may be capable for 
many months of reproducing the disease. 

In reference to what has been said concerning the slow spread of 
scarlet fever during epidemics in comparison with the rapid spread of 
measles, certain clinical facts are significant. The disease does not seem 
to be very infectious in its early stages. We are thus led to believe that 
it is during the stage of desquamation that the contagium is most likely 
to be disseminated. Measles, on the other hand, is known to be highly 
infectious in its early stages, and for this reason to spread more quickly. 

Although the contagium of both diseases may be active through their 
whole course, yet the general rule is early infection in measles, late in 
scarlet fever. The following cases illustrate this conclusion : 

A boy six years old and a girl four years old slept in the same room, with their 
beds touching each other. The boy was taken sick May 1, but remained in the same 
room with his sister during that day and the following night. He was seen by me 
early on the morning of May 3, and was then found to have scarlet fever. His sister was 
taken to the country, and the boy was left in charge of a trained nurse. There was 
absolutely no communication between the town-house and the country-house, either by 
people, clothes, or letter. I myself did not again see the boy during his sickness, 
having placed him under the charge of another physician. 

On June 1 I was called to see the girl, and found that she had scarlet fever. There 
were no other cases of scarlet fever in the vicinity of the country-house where she had 
remained since leaving the city. 

The boy at this time was desquamating freely, and four days previous to the girl's 
being taken sick a letter written by him had been sent to her, and she, after having had 
it read to her, had been allowed to keep it under her pillow. 

A careful study of this case led to but one conclusion, — that the boy during the 
period of his desquamation had infected his sister at a distance of twenty miles by en- 
closing the contagium of scarlet fever in an envelope. The girl, although she had been 
in the same room with the boy for thirty-six hours at the beginning of the disease, and 
although susceptible to the disease, had not contracted it at that time, owing to its very 
slightly infectious nature in its early stages. On the other hand, the stage of incubation 
of scarlet fever being only a few days, and many instances having proved that the dis- 
ease is very infectious during its period of desquamation, it was evident that the girl 
had been infected by means of the letter. 

In the following year, on May 20, I was again called to see the same boy. He had 
been well in the morning, but in the afternoon was found to have a high pulse and tem- 
perature, with coryza and lachrymation, so that it was deemed best to send the sister, 
who had been in the nursery only a few hours with her brother after he had been taken 
sick, to another house, while the boy was absolutely isolated. Three days later the 
boy was found to have measles. Ten days later the girl was attacked by measles. This 



SPECIFIC INFECTIOUS DISEASES. 



545 



case merely emphasizes the now commonly accepted belief that measles, in contradis- 
tinction to scarlet fever, is highly infectious in the early hours of the disease. 

Whether the contagium of scarlet fever can be carried by the breath 
is somewhat doubtful, but it is probable that any of the excretions may 
contain it, and that it is especially liable to be transmitted by milk, cloth- 
ing, toys, books, carpets, and other articles. Scarlet fever may occur in 
certain animals, and the contagium may be transmitted by others, such 
as dogs and cats. 

An instance which leads me to believe that scarlet fever may be trans- 
mitted at a very early stage of the disease is the following : 

A child who had contracted scarlet fever a few days previously came to a party 
given in a small and practically isolated community. At this time the child was begin- 
ning to feel sick and to complain of a sore throat. A spoon which had been used by 
her was also used, before it was washed, by one of the other children. Six or seven 
days later this second child was attacked by scarlet fever. 

A careful and critical investigation of the possible origin of the second case re- 
sulted in the evidence strongly pointing towards a direct transmission of the contagium 
from the mouth of one child to that of the other by means of the spoon. 

Scarlet fever may occur at all ages, but is rare during the first year of 
life. It has been met with in young infants who were nursing, and who 
have proved to be the focus of infection for a whole household. 

The following table was compiled by McCollom. It represents the 
age and the number of deaths in one thousand cases of scarlet fever 
treated in the contagious wards of the Boston City Hospital : 

TABLE 65. 



One Thou 


sand Cases of Scarlet Fever, by Ages, with the Deaths. 




Years. 


Cases. 


Deaths. 


Years. 


Cases. 


Deaths. 


Under 1 vear 


9 

24 

66 

115 

99 

124 

106 

64 

62 

58 

53 

21 

20 

23 

10 

12 

10 

7 

9 


2 

8 

20 

21 

9 

7 
6 

i 

3 
1 

1 





1 


19 years 


10 

7 
8 
8 
15 
9 
i 
5 

6 
3 
9 
3 
3 
2 

1 

1 
1000 


1 


1 year 


1 20 years 





2 vears 


1 21 years 


3 


3 years 


22 vears 





4 years 


23 years 





5 years 


24 years 





6 years 


25 years 





7 years 

8 vears 


! 26 years 





27 vears 


1 


9 vears 


j 28 vears 


1 


10 vears 


29 years 

30 years 





11 years 





12 years 


31 years 





13 years 


32 years 





14 years 


33 vears 





15 vears 


34 years 

35 years 

41 years 

50 vears 


o 


16 years 


o 


17 years 





18 years 







98 



35 



546 PEDIATRICS. 

Pathology. — The organs primarily affected in scarlet fever are the 
skin and the throat The principal complications which arise in the course 
of the disease are connected with the ear and the cervical glands. The 
chief sequela, and the only one which is at all common, is nephritis. 
Cardiac disease may occur, but is commonly secondary to the nephritis. 

Lesions of the other organs are somewhat unusual and have no defi- 
nite connection with the scarlet fever. They are generally due partly to 
the fever, partly to the septic processes which have arisen in the course 
of the disease, and are essentially those of acute inflammation with cellu- 
lar exudation, and with focal necrosis of the liver and kidneys. The 
changes are a marked infiltration of leucocytes in the tongue and in the 
desquamating skin. The internal organs show an infiltration with plasma- 
cells, and this is especially noticeable in the kidney in the acute interstitial 
form of nephritis. A proliferation of cells is found in the follicles of the 
lymph-nodes, and these cells are also often found infiltrating the coats of 
the veins, seeming in many places only to penetrate the endothelium and 
forming plugs in some of the smaller vessels. Hyperplasia of the lymph- 
nodes is a constant and marked characteristic. As a rule, the spleen is 
enlarged and shows marked follicular hyperplasia. (Pearce.) 

Skin. — Macroscopically the morbid conditions of the skin in scarlet 
fever, although varying in their manifestations, are usually represented by 
an intense general erythema covered thickly with minute macules, which 
are of a darker red than the accompanying hyperemia. Minute white 
spots may also appear thickly scattered over the reddened surface, prob- 
ably arising from areas of unaffected skin existing in the midst of the 
general hyperemia. An appearance like that of milium is also at times 
noticed to be scattered on the areas of skin affected by the erythema. 
No evidence of this hypersemic condition, which is so pronounced during 
life, is found after death. 

According to Neumann, microscopic examinations of the skin by 
means of hardened sections of specimens from cases of scarlet fever and 
measles in the stage of desquamation explain in a measure why the 
former is so much more likely to be infectious during its stage of desqua- 
mation than is the latter. In contradistinction to the pathological pro- 
cesses which are found in the skin in measles, and which affect chiefly 
the blood-vessels and glands, a very different picture is presented on 
examination of sections of skin taken from cases of scarlet fever. In the 
latter we find the pathological process represented especially by exudative 
cells, which are very numerous and closely packed together, reaching 
even up to the horny layer of the epidermis. Occasionally these exudative 
cells may finally take the place of the epidermal cells, appearing on the free 
surface of the skin, and are gathered thickly among the excretory ducts 
of the cutaneous follicles. It is thus readily understood why the tissue 
proper of the skin and its epidermis present no marked changes in measles, 
and why the epidermal cells are far less likely to carry the contagium than 



SPECIFIC INFECTIOUS DISEASES. 547 

in scarlet fever, in which the possibility of contagium exists until the des- 
quamation has entirely ceased. 

Throat. — The earliest lesions of scarlet fever appear on the mucous 
membrane of the hard and the soft palate. This appearance is very 
similar to the efflorescence which is seen on the skin, except that the 
minute white spots do not appear on the congested mucous membrane. 
Forchheimer states that the exanthem of scarlet fever appears from twelve 
to twenty-four hours before the efflorescence ; it appears upon the pillars 
of the fauces in the form of the characteristic puncta, then rapidly spreads 
over the mouth in the form of a scarlet-red coalescing efflorescence, which 
finally ends in desquamation, producing the strawberry tongue, and lasting 
well into the second week of the disease. These pathological conditions 
which occur in the throat in scarlet fever may either be simply catarrhal, 
or result in one of the more severe inflammatory conditions affecting the 
tonsils, the pharynx, and the larynx. 

The tonsils are uniformly and extremely bright red, and are thus to 
be differentiated from their dusky red color in cases of diphtheria before 
the membrane has appeared. On the hard and soft palate a punctate 
efflorescence is seen, and this appearance in from twenty-four to forty- 
eight hours may assume a yellowish color not ordinarily seen in catarrhal 
conditions of the throat or in diphtheria. 

When a membrane is seen it is impossible without a culture to differ- 
entiate conclusively from diphtheria. In many cases, however, we can 
make a fair diagnosis by the color of the membrane in scarlet fever being 
whiter and the thickness less, as a rule, than in diphtheria. 

As is stated by Delafield and Prudden, one of the most marked 
features of scarlet fever is the predisposition which it entails to the incur- 
sion of pathogenic germs other than those which we believe to cause this 
disease. Thus, in addition to the inflammatory lesions produced by the 
scarlet fever organism an acute exudative inflammation of the mucous 
membrane may occur, and may be associated with them. This is appa- 
rently caused by the growth of a streptococcus which, according to Welch, 
in morphological and biological character seems to be identical with the 
streptococcus pyogenes. In these cases there may be much or little fibrinous 
exudate, and there may be none at all in the early stages, or even through 
the whole course of the affection. The pellicle when formed may be 
more or less adherent, and sharply circumscribed, or it may tend to spread. 
The submucous tissue may show little change, or much congestion and 
oedema, or it may be the seat of suppurative inflammation. The entire 
process may be confined to the tonsils. While under these varying con- 
ditions the inflammatory process is usually a local one and runs its 
course, with or without the symptoms of septica&mia. occasionally the 
streptococcus finds access to the blood and may induce the lesions of 
pyaemia. On the other hand, it may by inhalation gain access to the 
lungs and induce varying phases of complicating broncho-pneumonia. 



548 PEDIATRICS. 

The staphylococcus pyogenes is not infrequently associated with the strep- 
tococcus in these lesions, but it is not apparently of great significance. 
Simulating very closely as it does in many cases both the local and the 
general phenomena of diphtheria, this pseudo-membranous condition was 
formerly confounded with it, but it is now recognized as a distinct 
disease. 

There have been a number of extended investigations made on what 
are called the pseudo-membranous inflammations of the throat in scarlet 
fever. Booker has reported eleven cases of pseudo-membranous angina 
(two fatal) complicating scarlet fever, and one case of simple angina with- 
out exanthem in a family three members of which had scarlet fever. In 
all these cases, as well as in four scarlatinal anginas without pseudo-mem- 
branes, Booker found streptococci as the predominant organism, and in 
none was the Klebs-Loeffler bacillus present. The staphylococcus aureus 
was found in eleven cases without apparent influence on the severity of 
the disease. No difference was observed between the early and the late 
pseudo-membranous anginas in regard to the bacteria present. Booker 
describes with much detail the morphological and bacteriological charac- 
teristics of the streptococci found, and divides them into groups. 

Park, in a series of one hundred and fifty-nine cases, reports nineteen 
cases of pseudo-membranous inflammation of the throat complicating 
scarlet fever. In seventeen of these cases streptococci predominated, 
and in only two was the Klebs-Loeffler bacillus present. Staphylococci 
were found in only a few cases. Williams has also reported cases of this 
kind, and Morse has reported ninety-nine cases of pseudo-membranous 
inflammation of the throat complicating scarlet fever. The Klebs-Loeffler 
bacillus was found in twenty-three, with a mortality of forty-three per 
cent., and was not found in seventy-six, with a mortality of twenty-one 
per cent. 

Finally, we may conclude that in scarlet fever the mucous membrane 
of the throat is rendered peculiarly vulnerable to the invasion of patho- 
genic germs. When the morbid condition in the throat is represented by 
a pseudo-membrane it will be found that in the great majority of cases 
the process, as stated by Welch, is due to streptococci ; but when diph- 
theria is prevalent and the opportunities are favorable for exposure, a 
large portion of the pseudo-membranous cases may be due to the Klebs- 
Loeffler bacillus. 

In addition to the lesions of the throat just described, the micro- 
organism of scarlet fever may attack the nasopharynx. In this way, and 
by direct extension through the Eustachian tubes, secondary aural lesions 
may be produced. The morbid changes in the mucous membrane of the 
nasopharynx which thus take place may result in a thickening of the 
tissues, which in some cases lasts for many months after the scarlet 
fever has run its course. 

Ear. — The pathological condition of the ear which is most commonly 



SPECIFIC INFECTIOUS DISEASES. 549 

met with in scarlet fever is an acute inflammation of the middle ear. 
This inflammation is likely to result in destruction of tissue, the formation 
of adhesions, the establishment of a long-continued suppurative process, 
and an accompanying necrosis. 

Cervical Lym.ph-Nod.es. — -There may be hyperplasia of the cervical 
lymph-nodes. This condition is sometimes accompanied by inflammatory 
oedema of the tissues of the neck, which may go on to suppuration and 
even to gangrene. In these cases streptococci are found in the glands and 
in the areas of suppuration. The infection is supposed to originate in the 
throat. The enlarged glands are, as a rule, indicative of secondary or 
mixed infection, although it is possible that the slighter forms of enlarge- 
ment may be due to reflex irritation with resulting hyperplasia from the 
scarlet fever contagium. In the severe form the glands are at times very 
much enlarged, and when a gangrenous process results the blood-vessels 
may be affected to such an extent as to be ruptured. 

Kidney. — In scarlet fever, as in a number of other infectious diseases, 
there are certain poisons produced in the course of the disease which are 
probably soluble in character. The results of bacteriological cultures in 
scarlet fever have shown that in a number of cases there is a general strep- 
tococcus infection, the infection probably coming from the lesions in the 
pharynx. In these cases of general infection streptococci may be culti- 
tivated from most of the organs of the body, there being a general septi- 
caemia. In a number of these cases extensive lesions may be found in 
the kidneys, and yet these lesions may bear no relation whatever to the 
presence or absence of streptococci. In like manner, streptococci may be 
found in the kidney without any lesion of the kidney. These lesions are 
diffuse, and affect both kidneys and all parts of the kidney. From the 
best evidence which we have it would seem that the virus, or whatever it 
is which produces the lesions in the kidney, is not a living organism, but is a 
soluble chemical poison produced by the organisms of scarlet fever, or by 
other organisms located in some other part of the body. This soluble 
poison when produced elsewhere is taken locally into the blood and affects 
various parts of the economy. In post-mortem examinations of scarlet 
fever certain lesions will usually be found in the kidneys. 

These lesions, according to Councilman, may be divided into two 
classes, (1) represented by simple degeneration of the epithelium, and (2) 
represented by marked changes in the tissues of the kidney. 

In the first class of cases the soluble poison may only affect the integ- 
rity of the capsular epithelial cells of the glomeruli. The poison may 
produce certain degenerative changes in these, but need not be accompa- 
nied by any proliferation of cells, or by any condition which would be 
characterized as inflammatory. It is more than probable that these sim- 
ple degenerative lesions are accompanied during life by evidence of albu- 
minuria, and in case death takes place there may be no macroscopic 
evidence of any lesions in the kidneys. Careful microscopic examination, 



550 PEDIATRICS. 

however, will show a condition of degeneration in the capsular epithelium 
of the glomeruli. Associated with this there will usually be found cloudy 
swelling of various degrees of intensity in the cells of the convoluted and 
the smaller collecting tubules. The degeneration here is rarely of a fatty 
character. Clinically, in the purely degenerative changes there may be 
only albuminuria with the presence of faint hyaline casts, and here and 
there a few leucocytes. 

In the second class, owing to a greater intensity in the action of the 
poison, or to some possible difference in its character, more marked changes 
may take place in the kidney, and may be accompanied by the degenera- 
tive lesions which are distinctive of the first class. Different forms of 
lesions may occur in the second class, and, according to the predominance 
of one form over the other, may characterize a special form of renal dis- 
ease. These lesions may be divided according to their anatomical distri- 
bution into interstitial, in which there is marked proliferation of the inter- 
stitial tissue of the kidney, and glomerular, in which the lesions are chiefly 
confined to the glomerulus and its capsule. 

In the interstitial form there will be found in the interstitial tissue be- 
tween the tubules accumulations of cells, the source of which is not clear, 
although they probably come from the blood. Most of these cells have 
the character of plasma-cells, but among them are a few lymphoid cells 
and polynuclear leucocytes. This form of nephritis should be considered 
as purely interstitial, since its lesions are in no way related to those of the 
epithelial tissue. There is both a general and a focal infiltration of cells 
in the interstitial tissue. The focal infiltration is found principally in the 
cortex of the kidney and about the glomeruli, the glomerulus frequently 
appearing as a centre from which the infiltration extends into the intersti- 
tial tissue between it and the surrounding tubules. 

This form of nephritis was first described by Wagner as the lymphoid 
kidney. The kidney, macroscopically, is swollen ; the capsule is easily 
stripped from the cortex, and is moist, whitish, and opaque. Usually there 
is no evidence of hemorrhage, although in some cases points of punctiform 
hemorrhage may be found in the cortex and in the intermediate zone. 

Clinically, in this form there may be little evidence of the severity of 
the lesions. There may be, however, albuminuria corresponding to what 
is seen in the purely degenerative class. The quantity of the urine may 
be very little diminished, and casts may be present, as well as a certain 
number of desquamative epithelial cells and leucocytes. 

These lesions are not confined to scarlet fever, but may be found in 
diphtheria, in measles, and in other infectious diseases of children, but they 
are not common in the infectious diseases of adults. 

Fig. 125 represents a microscopic section, made by Councilman, and is 
a good example of these interstitial lesions in scarlatinal nephritis. The 
section was taken from a case of pure scarlet fever. There was no 
anuria and no dropsy. The kidneys were enlarged, whitish, and without 



SPECIFIC INFECTIOUS DISEASES. 



551 



hemorrhage. Cultures from this case gave a general infection with strep- 
tococci in all the organs except the kidney, and yet the kidneys, notwith- 
standing the extent of their lesions, were found to be free from strepto- 
cocci. The epithelium of the tubules was somewhat swollen. The tubules 

Fig. 125. 



0. 



m 



'?. 


















ire —"~ ?po 






W ^ H 




v^ 



Interstitial nephritis. Section of kidney from child with scarlet fever. (Hajtnack, ocular No. II. 

objective No. VIII. Tube closed.) 



themselves were slightly dilated, and the epithelium was more granular than 
normal. The interstitial tissue was much more extensive than normal. 
The spaces between the tubules were increased both by oedema and by 
cellular infiltration. In the interstitial tissue blood-vessels were seen filled 
with cells of the same character as those outside. It is probable that most 
of the cells outside the vessels came from proliferation of the cells of the 
blood-vessels. The round spaces in the interstitial tissue represent blood- 
vessels. 

Another form of nephritis, called the glomerular, is much more fre- 
quently found in scarlet fever than in any other of the acute infectious dis- 
eases of children, but is not so common as the acute interstitial form. In 
this glomerular form the chief lesion of the disease consists essentially in a 
proliferation of the capsular epithelium combined with hyperplasia of the 
connective tissue. 

The proliferation of the capsular epithelium leads to the formation of 
masses of cells within the capsule between the glomerular capillaries and 
the capsule. These cells evidently result from the proliferation of the 
capsular epithelium. As a result of this there may be greatly increased 
pressure on the vessels of the glomerulus, possibly with an obliteration 



552 



PEDIATRICS. 



of these vessels. The cellular infiltration in the interstitial tissue is not 
so extensive as in the other form. Accompanying these changes in the 
glomerulus there is almost always more or less hemorrhage both in the 
tubules and in the interstitial tissue. 

Fig. 126 represents a section made by Councilman of glomerular ne- 
phritis. This section was taken from a case of scarlet fever complicated 
by glomerulo-nephritis. In the centre of the field a glomerulus is seen, 

Fig. 126. 




Capsular glomerulonephritis. Section of kidney from child with scarlet fever. (Hartnack, ocular No. 
II., objective No. VIII. Tube closed.) 



with an infiltration of cells in the capsular space. The capsular cells are 
oval and distinctly epithelial in character. Cellular proliferation of the 
cells having generally the character of those in the section of interstitial 
nephritis (Fig. 125) is to be seen in the interstitial tissue. In the tubule 
at the left upper corner there is evidence of hemorrhage, and some hemor- 
rhage is also to be noticed in the interstitial tissue on the right of the 
specimen. In this case the anuria and dropsy were extreme. 

This form of nephritis may be best designated as capsular glomerulo- 
nephritis. The kidney is sAvollen and much more hyperaemic than in the 
interstitial form. The markings of the cortex either are obscured or can- 
not be made out at all, and there are numerous areas of hemorrhage and 
hyperemia, giving the kidney a mottled appearance. 

It is this capsular glomerulo-nephritis which gives the most marked 



SPECIFIC INFECTIOUS DISEASES. 553 

clinical evidence of the extent of the lesions in the kidney. In this form 
dropsy is almost always present, the amount of urine is greatly dimin- 
ished, and in the more severe cases there may be complete anuria. 
Blood-casts are found more frequently in the urine than in the interstitial 
form. The diminution in the amount of the urine points to involvement 
of the glomerulus. Even severe cases of this form may be recovered 
from. The process of cell-proliferation may cease, the cells formed in 
the capsular space may disappear and pass out, and the kidney in after- 
years may show few or no evidences of the process through which it has 
passed. In a certain number of cases, however, from this form of nephritis 
a chronic nephritis is developed. Cases of this kind have been reported, 
notably one by Aufrecht. 

In both the interstitial and the capsular glomerulo-nephritis fatty de- 
generation of the epithelium is not found to any degree. The epithelium 
is frequently swollen and granular, and may be hyaline. 

These two forms of nephritis should be separated from each other, 
although transitions between their lesions are found. Usually they can be 
distinguished microscopically. 

We can, therefore, recognize three pathological conditions of the kid- 
ney in scarlet fever : first, the purely degenerative ; second, the acute inter- 
stitial ; and third, the capsular glomerular. 

Heart — The pathological conditions of the heart which are at times 
found in scarlet fever do not differ in their macroscopic appearances from 
those met with in other diseases. Cardiac disease occurring in the course 
of scarlet fever may arise in two ways : (1) from the general septic con- 
dition existing during the period of the height of the temperature and 
general efflorescence, and represented usually by an endocarditis ; (2) at 
a much later period from a nephritis which has arisen as a complication, 
and following which, from the resulting increased blood-pressure, en- 
largement of the heart has been produced, which may be represented by 
hypertrophy or by dilatation, or by both. 

In connection with this subject, Silbermann has found on examining 
a large number of cases of nephritis during attacks of scarlet fever a 
decided hypertrophy of the heart combined with dilatation. In some 
cases both sides of the heart were equally affected, but usually only the 
left side was involved. In only a few cases was there found a partial 
fatty degeneration of the muscular fibres ; the endocardium, pericardium, 
and blood-vessels were normal. According to Silbermann's observations, 
the cardiac affection was related to the post-scarlatinal nephritis, and not 
to the scarlet fever process itself, as the hypertrophy was never found 
when the child died in the early weeks of the scarlet fever. He calls atten- 
tion to the short period which intervened between the first appearance of 
the nephritis and the consecutive heart hypertrophy, in many cases the 
time not being much longer than a week. He also noticed that in the 
cases in which hypertrophy and rapid dilatation followed the acute ne- 



554 PEDIATRICS. 

phritis of scarlet fever the ages of the children were three and a half, 
four, five, and six years, and the post-scarlatinal cardiac enlargement 
corresponded to the physiological hypertrophy referred to on page 91. 

Incubation. — The stage of incubation of scarlet fever is uncertain and 
irregular, but, as a rule, it is shorter than that of any of the other ex- 
anthemata. It is usually less than seven days, and quite frequently it is 
only from two to four days. 

Variations in the Type of Disease. — Scarlet fever may be divided into 
two forms, the benign form and the malignant form. The difference in 
the symptoms of the common, or benign, form of the disease from those 
of the rare, or malignant, form is very striking. They could well be 
classified as entirely separate diseases, were it not that the contagium has 
been proved to be the same in each, by the fact that one form of the dis- 
ease may give rise to the other in different individuals. It seems as 
though it were more the susceptibility of the individual to the scarlet 
fever contagium than the contagium itself which produces a greater or 
less severity of the symptoms. 

BENIGN FORM OF SCARLET FEVER. 

The benign form of scarlet fever either runs a simple typical course or 
is accompanied by variations and complications, which makes its course 
irregular. 

Symptoms. — Prodromata. — The invasion of the disease is usually sud- 
den and, as a rule, active. The child feels very sick, looks dull, com- 
plains of sore throat and nausea, and in a large number of cases vomits 
continuously. The vomiting usually ceases in the stage of efflorescence 
and often before the prodromal stage has ended. The pulse is rapid. 
The temperature is high,— 39.4°, 40°, 40.5° C. (103°, 104°, 105° F.). 
In infants and very young children if the temperature rises to 40° or 
41.1° C. (104° or 106° F.) convulsions are very likely to occur. The 
higher the temperature at the beginning of the disease the more active 
the symptoms, and the shorter the prodromal period the more severe will 
be the case. An initial temperature of 40° C. (104° F.) points towards 
a severe case. 

Young children seem to show a less sensitive condition of the throat 
than is met with in older children and in adults. The appearance of the 
mucous membrane of the throat, although perhaps not characteristic, as 
at times a simple non-infectious pharyngitis may simulate it quite closely, 
is, in connection with the general symptoms, at least suggestive. The 
mucous membrane of the hard and the soft palate and of the pharynx is 
much congested. On the hard and the soft palate thickly scattered over 
the reddened surface are minute macules the color of which is a little 
darker red than that of the intervening mucous membrane. This condi- 
tion represents the earliest stage of the efflorescence which later appears 
on the skin. 



SPECIFIC INFECTIOUS DISEASES. 555 

The length of the prodromal stage varies, as a rule, from twelve to 
thirty-six hours. During this stage the temperature continues to rise 
somewhat, and at its end the efflorescence appears on the skin. 

Efflorescence. — The efflorescence of scarlet fever is of an erythematous 
and punctate character, sometimes looking as though minute macules had 
been sprinkled over the general redness of the skin. It starts on the 
front of the neck and the upper part of the chest, and rapidly extends 
all over the body and extremities, and upward to the face. This charac- 
teristic order of invasion of the skin aids us in distinguishing the efflores- 
cence of scarlet fever from that of the common erythema which occurs 
in such diseases as pneumonia, and in cases in which certain drugs, such 
as belladonna, have affected the skin and the efflorescence comes out 
everywhere at once and has an irregular distribution. It also enables us 
to distinguish the disease from measles, in which the efflorescence begins 
on the sides of the neck and on the face and extends downward. On 
gently drawing the finger over the efflorescence of scarlet fever the result- 
ing white mark remains longer than is the case with a common erythema. 
The efflorescence of scarlet fever continues to extend over the body for 
two or three days after its first appearance. During this period the 
tongue is much reddened and its papillae appear very prominent, consti- 
tuting what has been called the " strawberry tongue." This condition is 
to be distinguished from the enlarged papillae seen at an earlier stage of 
the disease on the tip and sides of the tongue. McCollom, in a study of 
one thousand cases, describes this latter condition as diagnostic of scarlet 
fever. There is at times in this stage great irritation of the skin. 

There may be slight delirium even in mild cases during the stage of 
efflorescence. This delirium may be very active and yet not be of serious 
import, provided the temperature remains moderate. 

The temperature rises when the efflorescence appears, and reaches its 
maximum at the end of the outbreak, in uncomplicated cases, but there 
is no decided rise just before or fall after the height of the efflorescence 
as is the case in measles ; on the contrary, the temperature slowly di- 
minishes until the ninth or tenth day from the beginning of the prodro- 
mal symptoms, when it becomes about normal, showing no decided crisis 
such as is seen in measles, but representing a defervescence by lysis. 
Chart 20 represents the temperature as it commonly occurs in cases of 
scarlet fever of the benign and regular form. 

The pulse is accelerated during the period when the temperature is 
elevated, and corresponds to it. It varies from 120 to 160. 

Desquamation. — The stage of desquamation begins at about the 
seventh day from the time when the efflorescence first appears, and 
in the parts of the skin first attacked. The desquamation, however, 
is not always proportionate to the intensity of the efflorescence. It 
is at first composed of small particles of cutis, but these soon become 
larger, and early in the third week from the beginning of the disease 



556 



PEDIATRICS. 



they fall from the body in large flakes. This form of desquamation 
is called lamellar. Here, again, we have an important means of dis- 
tinguishing scarlet fever from measles, for in measles the desquamation 
is almost universally of a furfuraceous character throughout the whole 











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Benign and regular form of scarlet fever. 



course of the disease, while the characteristic desquamation of scarlet 
fever is lamellar. This lamellar form of desquamation may at times, in 
certain individuals, and following the more intense inflammations of the 
skin, be represented by large and extensive pieces of skin. This is well 
shown in a specimen in the Warren Museum, where large strips of skin 
have come from the hand of a patient with scarlet fever so as almost to 
form a glove. 

Sometimes the desquamation lasts only ten days, but it may continue 
for two or three weeks. It is especially slow in disappearing from the 
hands and feet, and it may remain between the fingers and toes for a 
number of weeks. Sometimes after the desquamation- has apparently 
ceased and the skin has been smooth and normal for several days it may 
begin again, and thus prolong the period of convalescence. 

Urine. — The urine is lessened in amount during the prodromal stage, 
returns to the normal amount in the stage of efflorescence, increases 
during the stage of desquamation, amounting at times to a polyuria, and 
returns again to the normal amount at the end of this stage. During the 
stage of efflorescence, especially if the temperature is considerably 
heightened, there may appear in the urine a small amount of albumin, 
but this disappears as the temperature subsides, is probably only the 
result of the fever, as in many other diseases accompanied by a high 



SPECIFIC INFECTIOUS DISEASES. 557 

temperature, and is not to be confounded with the albuminuria of the 
nephritis which in some cases complicates the stage of desquamation. 

There is considerable reason to suppose that a mild form of nephritis 
accompanies almost every case of scarlet fever, although in many cases no 
clinical symptoms pointing towards the kidney appear and nothing ab- 
normal is found on examination of the urine. This statement, however, 
rests to such a degree on the authority of the general practitioner, rather 
than on that of the expert in urinary analysis, that we shall probably in 
the future find the number of cases which show nothing abnormal in the 
urine greatly lessened when the number of expert examinations of the 
urine in mild cases of scarlet fever has increased. 

Diagxosis. — The diagnosis of the benign and typical form of scarlet 
fever is not difficult. Its incubation is decidedly short in comparison 
with that of any of the other exanthemata. Its prodromal stage is 
short in comparison with that of variola and measles, and longer than 
the exceedingly brief prodromal stage of varicella. The characteristic 
prodromal symptoms of sore throat and a general and intense hyperemia 
of the mucous membrane, accompanied by vomiting and severe constitu- 
tional symptoms, make it easy to differentiate it from measles, varicella, 
and variola, none of which, as a rule, show these symptoms. 

The punctate erythematous lesions which appear in the stage of 
efflorescence of scarlet fever are rarely met with in any of the other dis- 
eases of this group. This efflorescence, beginning on the neck and chest 
and extending upward and downward, is distinguished by its peculiar 
distribution from that of the other members of the group. 

The efflorescence which in certain cases appears after the use of anti- 
toxin may simulate so closely the efflorescence of scarlet fever that in the 
first twenty-four to forty-eight hours it cannot be differentiated excepting 
by the appearance of the throat. In this connection it must be remem- 
bered that the antitoxin efflorescence may appear in forty-eight hours, 
and again not for three weeks. 

The lamellar desquamation is very characteristic, and is seldom seen 
in any of the other exanthemata. One of the earliest manifestations of 
the desquamation is a white seam around the base of the nails. (Mc- 
Collom.) 

The complications arising in the ear, and the occurrence of nephritis 
as a common sequela in scarlet fever, do not to the same degree find 
their counterparts in varicella and measles. 

Progxosis. — The prognosis of the benign and regular form of scarlet 
fever is in almost every case favorable. It is comparatively rare for the 
symptoms to become sufficiently serious to cause death unless some com- 
plication has arisen in the course of the disease. The individual who 
succumbs to the simple uncomplicated form of scarlet fever, even when 
the initial temperature is high and the symptoms are severe, as a rule 
must have been unusually vulnerable to the toxic effect of the scarlet 



558 PEDIATRICS. 

fever contagium, or must have had a very low degree of vitality at the 
beginning of the disease. 

Prophylaxis. — There is no known prophylactic against scarlet fever 
except isolation, which for many reasons should be rigorously enforced. 
We must remember the fact that when the child has passed its tenth 
year the chances of its ever contracting the disease are very much lessened. 
We must also appreciate that it is especially important to protect children 
who are learning, or who have just learned to talk. The commonly 
occurring and often intractable form of otitis which accompanies scarlet 
fever may not only render the child deaf, but in a case where the child 
has not learned to talk' it may lead to deaf-mutism. We should, there- 
fore, under all circumstances discountenance the opinion so often ex- 
pressed by the laity, and sometimes even by physicians, that it is well for 
children to have scarlet fever while they are young, on the ground that 
otherwise they will probably contract it at a later period of life, when the 
type of the disease may be more severe. The assertion that the type of 
the disease is more severe in adults than in children is not corroborated 
by my experience. 

Treatment. — An accurate knowledge of the chief pathological lesions 
which occur during the course of the disease enables us to deduce the 
appropriate treatment. By treatment is not to be understood simply the 
use of drugs. On the contrary, drugs are employed to entirely too great 
an extent in a large proportion of the uncomplicated cases of the benign 
type of scarlet fever. I feel that I can speak with some authority on this 
point, as it has been my rule for many years to compare the results of 
cases treated by my colleagues with drugs with my own cases treated 
without drugs, and certainly nothing that I have observed in this com- 
parison would indicate that my patients had suffered from want of treat- 
ment. We should have some definite reason for what we do, and should 
not be influenced by vague ideas of what drugs are supposed to be bene- 
ficial in certain diseases. 

The treatment of a case of scarlet fever is that of a self-limited disease.. 
With our present knowledge of it, the disease cannot be cut short. We 
should, therefore, endeavor to keep it within its own limits by avoiding 
complications. To do this we must remember which tissues are affected 
as part of the disease and which are likely to be affected by complications. 

In the first class we must consider the throat and the skin ; in the 
second class the ear and the kidney. 

At the onset of the disease the child, as a rule, is so profoundly affected 
by the scarlet fever contagium that it wishes to be put to bed at once.. 
The symptoms which from their intensity require treatment in the pro- 
dromal stage of the disease are the vomiting, the sore throat, and the high 
temperature. 

The vomiting, as a rule, is of such short duration, and is so symp- 
tomatic of nervous gastric disturbance caused by the toxic effect of the 



SPECIFIC INFECTIOUS DISEASES. 559 

poison, that it should be looked upon as eliminative, and usually does not 
require the use of anything but pieces of cracked ice to be held in the 
mouth. 

The treatment of the throat in scarlet fever is to be especially directed 
not only to allaying the temporary discomfort of the pharyngitis, but also 
to the prevention of the inflammatory process from extending through the 
Eustachian tube to the membrana tympani and producing an otitis which 
may result in a meningitis. This latter complication is rendered possible 
by the close vascular connection which exists in infancy and in childhood 
between the meningeal blood-vessels and the vessels of the tympanum, 
through the open petro-squamosal suture. 

Another reason for systematically treating the throat in all cases of 
scarlet fever is derived from the belief that the various secondary infec- 
tions which take place in the disease are probably caused by the entrance 
of pathogenic organisms to the various tissues through the inflamed and 
vulnerable mucous membrane of the pharynx. This invasion is com- 
monly of the cervical glands, the ear, the lung, the heart, and the kidney. 
If this belief is correct, antiseptic treatment directed to the throat is indi- 
cated as possibly preventive of the complications which may arise in the 
disease. 

For the purpose not only of allaying the irritation of the throat, but 
also of preventing the spread of the morbid process to the ear, if possible, 
the throat and the nose may be sprayed several times during the day. 
Solutions (two to three per cent.) of borate of sodium in water combined 
with a small amount of glycerin are useful for this purpose. A four per 
cent, solution of boric acid in water can also be used to advantage. The 
local treatment, however, should always be of the mildest form, since any 
additional irritation of the mucous membrane will render it more vulner- 
able to the streptococcus invasion. If the child knows how to gargle, the 
discomfort which arises usually from the sore throat during the first day 
or two of the disease may often be allayed by simply gargling with cool 
water. This procedure answers a double purpose : it not only reduces 
somewhat the hypersemic condition of the mucous membrane of the 
upper part of the throat and cleanses the anterior fauces, but also tends 
to prevent the extension of the pathogenic organisms which would neces- 
sarily be favored by a continuous recumbent position of the child. If the 
child is unable to gargle, some pieces of ice may be given to it to hold in 
its mouth, and it should occasionally be allowed to sit up, as when its 
nourishment is being given. 

However desirable this treatment of the throat and nose may be in 
scarlet fever, we are but too often baffled in our attempts to treat them 
locally, on account of the persistent resistance of the child. 

Chlorate of potash, which is so frequently used for the treatment of 
the throat in scarlet fever, is, in my opinion, a drug which in this disease 
it will be wiser not to allow the child to swallow, on account of its pos- 



560 PEDIATRICS. 

sible deleterious action on the kidney, which from the beginning of the dis- 
ease to its end is in so sensitive a condition as to be readily affected by 
any irritant. Doubtless in a large number of cases we should not be 
likely to cause renal irritation by the small doses of chlorate of potash 
which are usually given. Children, however, differ very much in their 
individual susceptibility to drugs, and we can never tell beforehand 
whether or not a child is liable to be injured by them. We know that 
the vegetable salts of potash are decomposed in the system and eliminated 
as alkaline carbonates, thus causing no irritation in the kidney. Nitrate 
and chlorate of potash, on the other hand, which do not part with their 
oxygen in the system, are excreted undecomposed by the kidney, and 
thus act as irritants. Knowing that the tendency during the whole course 
of the disease is towards a renal hyperemia, we should allow the child 
to have plenty of water to drink. 

Unless the child shows decided signs of suffering from a heightened 
temperature, antipyretics in the form of drugs by the mouth should not 
be used, as the cases are rare where a temperature of 38.8° to 39.4° C. 
(102° to 103° F.) for a few days will do harm. This is a safe rule to 
follow in a disease like scarlet fever, in which, if the child happens to be 
easily affected by fever, the unfavorable symptoms will appear at once 
and can be attended to. My opinion is that mere heightening of the 
temperature without correspondingly severe symptoms causes much need- 
less anxiety. In typical mild cases of the disease, knowing that a lessen- 
ing of the amount of the urine in the prodromal stage as a result of the 
high temperature is a part of the regular course of the disease, the admin- 
istration of diuretics is not indicated beyond a plentiful supply of pure 
drinking-water. Although the temperature may cause severe initial symp- 
toms, such as convulsions, as a rule it does not have to be directly treated 
during the prodromal stage. If, however, convulsions occur and continue 
and the temperature is unusually high, such as 40.5° or 41.1° C. (105° 
or 106° F.), and if it remains at this height with serious general symp- 
toms, such as delirium, we should endeavor to reduce it by sponging the 
body with water, the temperature of which should be varied according to 
the special case. To begin with, the temperature of the water should be 
about 32.2° C. (90° F.). The child is usually made more comfortable by 
bathing if the temperature is as high as 40° C. (104° F.). The reduction 
of temperature by water may be accomplished (1) by sponging, (2) by fan- 
ning the child's body wrapped in gauze sprinkled with water of a tempera- 
ture of 32.2° C. (90° F.), and (3) by placing the child directly in a tub of 
water and at the same time rubbing the body and limbs and giving a stimu- 
lant. The water in the bath should at first be 32.2° C. (90° F.), and 
gradually reduced five or ten degrees. In extreme cases the cold pack by 
means of wet sheets can be used ; the sheets should be removed in ten 
or fifteen minutes, the body and limbs rubbed, and a stimulant given. 

I have mentioned before that scarlet fever is rare during the first year 



SPECIFIC INFECTIOUS DISEASES. 561 

of life. There are certain observations which seem to show that nephri- 
tis is a rare accompaniment of scarlet fever during the first year. We 
know that milk is the food which is least irritating to the kidney. It 
w T ould, therefore, seem rational to make milk the diet in a disease which, 
like scarlet fever, points out to us by its pathology that we should as far 
as possible avoid irritating the kidney. It may be merely a coincidence, 
but it seems of some significance that the first year of life should also be 
the one which is least likely to present cases of scarlatinal nephritis. 

When the nausea and vomiting are present, the child, as a rule, feels 
too sick to take any nourishment whatever. When the violence of the 
toxic invasion has somewhat abated, and the diagnosis of scarlet fever 
has been made, orders should at once be given that the child is to have 
no food but milk. The treatment of scarlet fever with a diet purely of 
milk has in my practice proved so eminently satisfactory that it has be- 
come my routine treatment of the disease. During the initial stage of 
the disease, and until the stomach has recovered its equilibrium, lime- 
water should be added to the milk in the proportion of one part to ten. 
Later the alkalinity of the milk can be lessened, and after the early days 
of the efflorescence the milk may in most cases be given undiluted. As 
it is possible that the nitrogenous part of the milk may be too great, it is 
well to reduce the proteids to 2 or 3 per cent, and to increase the sugar 
to 6 or 7 per cent. The administration of milk alone should be continued 
through the stages of efflorescence and desquamation, and until we are 
justified in supposing that a nephritis will not develop in the special case. 
This in general may be estimated at from four to five weeks from the 
time of the height of the efflorescence and temperature. Perhaps in this 
way in a certain number of cases a nephritis may be warded off, and if it 
develops, the patient is already on a diet which is best suited to the 
disease. 

During the stage of efflorescence there are seldom any symptoms which 
require special treatment, in the regular form of the disease, except a con- 
siderable irritation of the skin which at times arises. This can be allayed 
by the application either of some simple ointment or of a powder of oxide 
of zinc and starch (Prescription 62, page 366). The use of the ointment 
is to be recommended not only because it keeps the skin soft and in good 
condition, but also because this application reduces the temperature some- 
what. Sponging the entire body with water at a temperature of 32.2° 
C. (90° F.), once or twice daily according to the comfort of the patient, 
is to be recommended. 

During the stage of desquamation the application of a simple oint- 
ment to the whole body is desirable both for the purpose of softening the 
disintegrated epithelium and lessening the duration of this stage, and also 
to prevent the spread of the contagium by means of the loosened scales. 

The child should be kept in bed until the desquamation has almost 
entirely ceased. This will cover a period of from four to five weeks. 

36 



562 PEDIATRICS. 

By the end of the fourth week, if the desquamation has completely dis- 
appeared, the diet can gradually be increased by the addition of soup and 
bread. It is well to keep the child in the house for five or six weeks, 
and still longer if the weather is cold or damp. 

The urine should be frequently tested for albumin during the first 
three weeks, and afterwards, when the child is first allowed to get up, 
after each change in diet, and after going out. If any albumin is detected, 
the child should be immediately put back to bed and on a diet of milk 
until the albumin has disappeared. The mild cases are the very ones in 
which a nephritis is liable to occur, and therefore we should watch vigi- 
lantly until they are out of danger, which is usually in the fifth or sixth 
week. 

Gordon reports a very severe case of scarlet fever with streptococci 
and staphylococci in the throat, in which rapid improvement occurred 
after two injections of 10 c.c. of anti-streptococcus serum under the skin. 
During an epidemic of scarlet fever, in which the mortality was 24.9 per 
cent., Baginsky treated forty-two cases with Marmorek's anti-streptococcus 
serum, with a resulting mortality of 14.6 per cent. He, however, points 
out the variability of the mortality figures in scarlet fever, and for this 
reason the possible error in attempting to draw any conclusions from the 
statistics with reference to the serum. 

Isolation and Disinfection. — The disease being eminently infectious, 
the patient with the nurse should be isolated to as great a degree as cir- 
cumstances will permit. An upper room should preferably be chosen. 
It has been observed in crowded parts of large cities that scarlet fever in 
tenement-houses is not so likely to spread when the first cases are in the 
top rooms of the tenements. In a number of instances in my practice I 
have had one child of a numerous family strictly isolated in the upper 
story of the house, and the other children have remained in the house 
without contracting the disease. 

The intensity of the lesions of the skin and the involvement of large 
surfaces indicate that the air of the room should be kept at an equable 
temperature, in order that the function of the disabled skin should be 
taxed as little as possible and that the internal organs should not have too 
great compensatory work forced upon them. The temperature should 
be kept at about 20° C. (68° F.). 

A disease which renders confinement to the room necessary for weeks 
demands a room with good ventilation and plentiful sunlight. Therefore 
a room on the sunny side of the house, having an open fireplace, should 
be chosen. 

The room should be free from all cotton or woollen materials except 
such as can be destroyed by fire at the end of the disease. The blankets, 
sheets, towels, and clothes can, of course, be disinfected, but it will save 
much ultimate trouble to remove the carpet and the curtains and replace 
them with pieces of old carpet and sheets. The pictures, and, in fact, 



SPECIFIC INFECTIOUS DISEASES. 563 

everything worth preserving, should be removed. The room can be 
made sufficiently cheerful by means of cheap colored prints and destruc- 
tible toys to amuse the child. 

During the whole course of the disease the greatest care must be taken 
to disinfect the linen of both the patient and the nurse. This should be 
done by soaking it for twenty-four hours in a five per cent, solution of 
carbolic acid, then boiling it for half an hour in water, and finally washing 
it with soft soap solution, 20 grammes (f ounce) to ten litres (10 J quarts) 
of water. 

The dejections are to be received in a vessel one-quarter full of a five 
per cent, solution of carbolic acid. 

After the child is entirely well it is to be thoroughly washed first in a 
solution of corrosive sublimate 1 to 10,000. The child is then to be taken 
to another room to be wiped and put into fresh clothes, which have 
not been in the scarlet fever room. The mattress is to be tied up in 
canvas wet with a corrosive sublimate solution 1 to 500, and sent out of 
the house to be disinfected, if possible by steam. I usually advise the 
family never to have it brought back again. In place of the mattress it is 
far better to use old blankets, which, if in sufficient number, are comfort- 
able, and at the end of the sickness can be thoroughly boiled and thus 
disinfected. The useless articles which have been in the room during the 
sickness should be burned in the open fireplace. 

The room must next be disinfected. This is a very difficult matter to 
do absolutely, but there are several methods which are far better than the 
usually recommended disinfection by sulphur which has been so generally 
used for this purpose during the past century. I mention sulphur as a 
disinfectant merely to state that it was proved by Koch as long ago as 
1881 to be entirely unreliable. 

If there be paper on the walls, it should be scraped off and immediately 
burned. The floor should then be washed with a solution of corrosive 
sublimate 1 to 500, followed by soap water (a mop should be used so as 
to avoid irritation of the hands). The ceilings, the walls, all the wood- 
work, and the furniture are to be thoroughly rubbed with bread and then 
wiped with the corrosive sublimate solution 1 to 500. Esmarch has shown 
that bread is the best means of removing infectious material from surfaces 
of this kind. The micro-organisms adhere with great tenacity to the bread, 
which, with any crumbs that break off and fall to the floor, must be care- 
fully collected and destroyed by fire. The room should then be thor- 
oughly vaporized for eight or ten hours with formaldehyde in the form of 
pastilles or liquid. For every 3500 cubic feet of space 250 grammes (250 
formalin pastilles) of formaldehyde should be used. This can be done 
with a vaporizing-lamp, the room first having been tightly sealed. 

Recent experiments show conclusively that formaldehyde is a reasona- 
bly good surface disinfectant, but does not penetrate deeply, and is not so 
efficient as steam. It is good for walls but not for mattresses or clothes. 



564 PEDIATRICS. 

It does not appreciably discolor papers or colorings, and does not affect 
metals. 

The room should then be aired for several days. If there are other 
children in the house, it is well to have the whole room painted, including 
the ceiling and the floor. 

The physician should also bear in mind that the hair, beard, and 
clothes are possible means of transmitting the contagium from one patient 
to another, and that it is his manifest duty to the public to change his 
clothing and disinfect himself on leaving a scarlet fever patient. 

The following case illustrates the benign type of scarlet fever without 
variation from the regular type and without complications : 

A boy four and one-half years old was noticed on November 6, when I was vac- 
cinating his sister, an infant, to be quite sick. Besides the infant the boy's two 
brothers, one two and a half years old and the other six, were in the room with him. 
The mother supposed that the boy had an attack of indigestion. He had been vomiting 
quite frequently and had no appetite. His pulse was 120. His temperature was 38.3° 
C. (101° F.). He had no headache and no sore throat, but he had the appearance 
somewhat characteristic of scarlet fever well marked on the hard and the soft palate. 
He was placed in an upper room of the house and completely isolated with a trained 
nurse. The vomiting continued until evening, when it stopped and did not return. 

On November 7 he was reported to have had a restless night. His throat was found 
to be very much reddened and to feel a little sore. His pulse was 135. His tempera- 
ture was 38.3° C. (101° F.). He had had a natural movement of the bowels. His 
appetite was poor. 

All unnecessary articles were immediately removed from the room, and he was 
confined to his bed. He was placed on a diet of milk and given as much water as he 
wished to drink. The efflorescence of scarlet fever very soon appeared on his chest. 

On November 8 the efflorescence had spread all over his body. He was reported 
to have slept well and to have vomited his milk but once. His pulse was 125, and his 
temperature was 37.7° C. (100° F.). He was sponged twice daily with water at a tem- 
perature of 32.2° C. (90° F.), and as the skin was somewhat irritable the itching was 
allayed with inunctions of vaseline. The temperature of the room was kept at 20° C. 
(68° F.). 

On November 9 the efflorescence had spread to the limbs, and was also present to 
a slight degree on the face. At 6 a.m. the pulse was 120, the temperature 36.6° C. 
(98° F.). At 6 p.m. the temperature was 37.2° (99° F.), and the pulse was 120. He 
had a little more appetite, his skin was less reddened, and his throat was not so sore. 

On November 11 the efflorescence began to fade, first on the chest. On November 
13 the temperature became normal, and desquamation began, first on the chest. On No- 
vember 25 the desquamation had almost ceased, and the boy was allowed to get up and 
play about the room for an hour. On December 1, the desquamation having almost 
ceased for several days, he began to desquamate freely again. On December 8 the des- 
quamation ceased. He was disinfected and then sent down-stairs among the rest of the 
children. He went out of doors December 25. 

No albumin was detected in his urine during the whole course of the disease. He 
resumed his usual diet on December 10. 

None of the other children contracted the disease, although they remained in the 
house while their brother was sick. 

Plate VIII. , facing page 564, is a picture taken from a boy ten years old on the eighth 
day from the time of infection, the fourth day from the beginning of the prodromal 



PLATE vni, 





SPECIFIC INFECTIOUS DISEASES. 565 

symptoms, and twenty-four hours from the beginning of the efflorescence. The efflo- 
rescence was in the form of a punctate erythema. 

Variations in Type of the Benign Form of Scarlet Fever. — In the 
benign form of scarlet fever we may have great variations from the 
typical manifestations of the disease. 

A heightened temperature in the evening sometimes continues for 
over a week after the efflorescence has faded, without the existence of any 
ascertainable cause : this occurrence should always be looked upon with 
suspicion. After a rapid increase of temperature at the beginning of the 
disease there sometimes ensues a condition of complete apyrexia, while 
all the other symptoms continue to develop in the usual manner. When 
the temperature remains heightened at the end of the period of efflores- 
cence and continues into the period of desquamation, especially when 
there is no local pain anywhere, we should suspect that a nephritis may 
be developing. When the temperature after having become normal rises 
again, we should suspect such complications as otitis media and suppura- 
tion of the subcutaneous tissues of the neck, or that the heart is involved. 

Relapses may take place in scarlet fever, but a true relapse is rare, 
and a second attack, either from auto-infection or reinfection from an- 
other individual must be taken into consideration. In the Bagthorpe 
Fever Hospital, out of two thousand cases fourteen had relapses while 
under observation. As pointed out by McCollom as a result of his studies 
in a series of one thousand cases at the Boston City Hospital, we may 
meet with (1) pseudo-relapses, where, after the disappearance of the efflo- 
rescence and at the very beginning of the desquamation, symptoms of the 
disease return ; (2) relapses, where after the efflorescence has disappeared 
and during the stage of desquamation the symptoms return ; (3) reinfec- 
tion, after desquamation has ceased for a time. The symptoms of these 
cases are sometimes more severe than those in the first attack, but in 
most of the reported cases of relapse in scarlet fever the first attack has 
been a mild one. Such cases occur usually in older children rather than 
in younger, and must be sharply distinguished from the cases in which 
a fresh infection has taken place and which are characterized as a second 
attack of the disease. Thomas reports a case of scarlet fever complicated 
by varicella, in which on the twenty-fifth day of the scarlet fever a re- 
lapse occurred, and on the twenty-sixth day a second attack of varicella 
developed. 

Certain cases of scarlet fever have been reported in which in the latter 
part of the disease, and after the temperature had become normal, the 
temperature rose to 40° to 41.1° C. (104° to 106° F.), when no cause 
could be discovered for the hyperpyrexia, and when the patients recovered 
after being promptly treated with cold baths to reduce the temperature. 

Scarlet fever may begin with such great cerebral excitement as to 
lead us to suspect meningitis, and it may not be possible to determine the 



566 PEDIATRICS. 

diagnosis until the efflorescence has appeared, which may not be until 
even the eighth or ninth day. 

The efflorescence may last only twenty-four hours, or continue four- 
teen days. In certain cases a recrudescence of the efflorescence may occur. 
In these cases, which may be showing a high temperature and a brilliant 
efflorescence, the efflorescence after about forty-eight hours disappears, 
but the temperature remains elevated, and the efflorescence again appears 
twenty-four hours later. We must remember that we are not to depend 
upon the efflorescence in making our diagnosis in scarlet fever, as it may 
be so evanescent as to be scarcely recognizable. Lemoine, during an 
epidemic in 1895 of two hundred cases, reports that in thirty-two of 
these cases the efflorescence was limited to the face. In some extremely 
mild cases the efflorescence may be entirely absent (scarlatina sine erup- 
tione) or evanescent, lasting perhaps only twelve hours. The papillae of 
the tongue, however, are enlarged, there is a slight efflorescence on the 
roof of the mouth, and the diagnosis should, therefore, be made from 
the mouth. Serious epidemics have been started by this class of cases. 
While in ordinary types of the disease the efflorescence is not very brilliant, 
there is another set of cases in which it is very brilliant and is accompa- 
nied by a high temperature, which remains elevated for four or five days 
and then often becomes normal as the desquamation begins. 

Convulsions occurring at the onset of the disease are not, as a rule, 
indicative of a fatal issue, but when they occur later they are usually of 
serious import. 

The occurrence of scarlet fever in surgical cases is of no special sig- 
nificance beyond the apparently greater susceptibility of patients with 
open wounds to contract the disease. We should bear in mind the sug- 
gestion of Osier, that in the majority of these surgical cases thus far 
recorded the efflorescence has probably been the red rash of septicaemia, 
and that the reported cases have become rare since the gradual disappear- 
ance of septicaemia as a complication of surgical operations. Atkinson 
also suggests that in many instances these rashes may have been due to 
the quinine which was given to the patient. 

A variation may arise from the ordinary scarlatinal inflammation of 
the mucous membrane of the throat when the efflorescence becomes more 
severe than usual, resulting in a membranous exudation in the throat and 
a profuse nasal discharge caused by streptococci and accompanied by very 
severe symptoms, delirium, and a high temperature for from twelve to 
fourteen days, the temperature coming down by lysis. The larynx in some 
cases may also present unusual symptoms, such as aphonia, and serious 
symptoms caused by a concurrent oedematous condition of the glottis may 
arise and produce even a fatal issue. 

In the benign form of scarlet fever certain cases are at times met with 
in which the high temperature, or the especial vulnerability of the child 
to the scarlet fever contagium, causes the symptoms to vary considerably 



SPECIFIC INFECTIOUS DISEASES. 



567 



from the typical form and to be unusually grave. An instance of this 
class of cases was one which was seen by me in consultation with Dr. 
Robert P. Loring, of Newton Centre. 

The child was a girl, six years old. The point of variation from the typical cases 
of scarlet fever was in this case an unusually high temperature. The invasion of the 
disease was characterized by restlessness and sore throat, which was soon followed by 
vomiting and delirium. The temperature on the first day rose to 41.1° C. (106° F.). 
The highest temperature was on the second and third days, when it reached 41.6° C. 
(107° F.). During the first three days the pulse could not be counted. The high tem- 
perature continued until the sixth day from the beginning of the prodromal symptoms. 
During the first forty-eight hours there was almost continuous vomiting. This was 
succeeded on the third day by frequent profuse, and often involuntary, serous discharges 
from the bowels. These discharges continued until the fifth day. On the fourth day 
a slight erythematous efflorescence appeared on the neck and chest, and on the fifth 
day it extended all over the body and was of an intense character. On the sixth day 
a complication of pain in the wrists began, but it disappeared in twenty-four hours 
under the administration of salicylic acid. At this time also there was marked swelling 
on the left side of the neck, which gradually disappeared in four or five days. 
When the fever was at its height there was considerable cyanosis, with quickened 
respiration. The pulse at this time was weak and difficult to count. From time to 
time during the attack antifebrin was given for the restlessness, and bromide of soda 
was occasionally used. Tincture of digitalis was given when the pulse was rapid and 
weak and cyanosis was present, but the treatment which was most depended upon was 
bathing. 

CHAET 21. 





J)ays of Dtsea.se 




F 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


II 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 


c 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORM't. 
TEMP 
98° 

97° 
96° 

95° 


SI K 


M K 


M E 


M E 


M E 


M E 


HI E 


M E 


M E 


M E 


M E 


U E 


M E 


M E 


M E 


M E 


51 E 


M E 


M E 


M E 


M K 


41,6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36 6° 

36.1° 

35.-5° 

.35.0° 




/ 


/ 


/ 


/ 


































D 


V 








































i 








I 


y 
































7 


! 










ll 






























7 


1 




' 




i 




A 




























± 










! 




V 


V 




A 


/ 




















f 


















V 


/ 


/ 


/ 


















t 


























/ 


/ 


s/ 


/ 










T. 


.... 




























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V 


V. 


y 











































































































































Toxic symptoms and high temperature in scarlet fever treated by baths. 



The method of bathing for the purpose of reducing the temperature was that of 
placing the child in a tub of water. Whenever the temperature reached 40.5° C. 
(105° F.) the child was placed on a pillow in the bath, and was kept there until the 
temperature was reduced three or four degrees. The time required to accomplish this 



568 PEDIATRICS. 

was usually from one to one and a half hours. While the child was in the bath stimu- 
lants and milk were given to it. The temperature of the water was about that of the 
child, and was gradually reduced to about 32.4° C. (90.5° F.). During the first four 
days the child was either delirious or in a comatose condition, and when in the bath 
would pass its urine and faeces involuntarily. 

The high temperature continued until the sixth day from the beginning of the 
prodromal symptoms, when it fell decidedly, from which time the baths were omitted, 
and the temperature continued to fall by lysis until it reached the normal degree on 
the sixteenth day from the invasion of the disease. After this the child had no un- 
usual symptoms, and made a rapid recovery. There were no complications. The des- 
quamation took the usual course. 

Chart 21 shows the temperature in this case. The broken lines mark the degree 
to which the temperature was reduced by the baths. 

Complications of Scarlet Fever. — Most of the complications which 
arise in scarlet fever are due probably to the action of streptococci, either 
isolated or associated with other micro-organisms. These micro-organisms 
produce serious symptoms, which are often followed by death, either 
directly by giving rise to septicemic processes or indirectly by nephritis. 

It is supposed that the infection which complicates scarlet fever enters 
the system commonly through the pharynx either by direct absorption or 
by inhalation of these organisms. 

Throat. — Symptoms. — In addition to the milder forms of inflammation 
in the throat which occur in the course of scarlet fever, this simple in- 
flammation may be complicated by more severe lesions. In these cases 
there may be an exudation affecting the mucous membrane of the entire 
buccal cavity and throat, evidently produced by streptococci. This com- 
plication adds greatly to the severity of the scarlet fever, and is a com- 
mon source of invasion of the ear and of infection of the cervical glands. 
In addition to lesions of this class we meet at times with a membra- 
nous condition of the mucous membrane of the throat, the pathological 
lesions of which cannot be differentiated from those of diphtheria. This 
membranous condition is caused by the action of streptococci, and the 
diagnosis between these membranes and those which are produced by the 
Klebs-Loefller bacillus cannot be made except by means of a bacteriological 
examination. These more severe inflammatory conditions of the throat 
are not common in my experience outside of hospitals, but have been 
observed a number of times in our scarlet fever and diphtheria wards at 
the Boston City Hospital. In these cases of streptococcus invasion the 
entire throat may be very much swollen, the tonsils enlarged, and the naso- 
pharynx affected to such a degree as almost to occlude the nares. It is 
necessary to make a bacteriological examination of these lesions which 
have been called pseudo-membranes, if we wish to determine in the early 
days of the disease whether or not we are dealing with a case of diph- 
theria. After the first three or four days in most cases there is usually 
so marked a clinical difference between the progress of the disease in 
which the Klebs-Loeffler bacillus is present and that in which the exuda- 



SPECIFIC INFECTIOUS DISEASES. 569 

tion is simply secondary to a streptococcus invasion, that we are not long 
in doubt as to our diagnosis, even without the decisive proof by culture. 
As a rule, when the Klebs-Loeffier bacillus is present the continued in- 
crease in the severity of the symptoms and the resulting exhaustion of 
the child show us that we are dealing with this micro-organism. We 
must not, however, be misled by this general rule of differential diagnosis, 
for there are many cases in which it is impossible to differentiate between 
a streptococcus invasion and an invasion of the Klebs-Loeffler bacillus 
either by the appearance of the throat or by the clinical symptoms. On 
the one hand, the streptococcus invasion may be quite as severe in its 
symptoms as that of the Klebs-Loeffler bacillus, while, on the other hand, 
true diphtheria may occur where the symptoms are as mild as any that 
are produced by the other micro-organisms. 

Treatment. — The treatment of the throat in these severe secondary 
conditions is the same as in the treatment of the benign forms, except 
that, if possible, it should be carried out more rigorously. Although 
Seitz reports that he has had excellent results from the injection of 
carbolic acid into the tissues of the tonsils and soft palate, this treatment 
requires still further proof of its efficacy before it can be recommended. 
As the disease runs a comparatively short course, there is not such a 
need for stimulants as is indicated where diphtheria is present. In young 
children it is often impossible to treat the throat locally, and I have usually 
found that my chief reliance in tiding over the severe stage of the disease 
is the administration of sufficient food, and of stimulants wmen they are- 
indicated by the general condition of the child. It is to be remembered 
that the throat in scarlet fever may be attacked by the Klebs-Loeffler 
bacillus and the disease brought to a fatal issue by a complicating diph- 
theria. When diphtheria is present, the treatment should be the same as- 
for a primary case of diphtheria. 

In the more severe forms of inflammation in the throat the inflamma- 
tory process may go on to the formation of an abscess, as in the pharynx, 
but the most common place is in the tonsil or in its neighborhood. These 
abscesses must be carefully watched for, and when detected opened with 
antiseptic precautions as soon as possible. We shall by this treatment 
often shorten the course of the disease, and thus save loss of strength 
and vitality on the part of the patient. 

Cervical Lymph-Nodes. — Symptoms. — The cervical lymph-nodes of 
the neck are more or less enlarged, according to the severity of the infec- 
tion. This enlargement may in some cases be so great as to cause much, 
swelling and distortion of the face and neck. The swelling extends at. 
times under the chin from one ear to the other as a mass of cellulitis. 
The tissues of the neck under these conditions may, as described in speak- 
ing of the pathology of the disease, suppurate, and this condition, even if 
it does not produce a fatal result from gangrene, may greatly prolong the 
period of convalescence. 



570 PEDIATRICS. 

Treatment. — While the glands are enlarged and tender, the application 
of hot fomentations usually gives much relief, as does also in some cases 
an ice poultice. Beyond this I am not in the habit of making any exter- 
nal application. 

Ear.— Symptoms. — The middle ear is so closely connected by means of 
the Eustachian tubes with the naso-pharynx that aural complications are 
exceedingly common where naso-pharyngeal irritation exists. The symp- 
toms which indicate that a secondary infection of the ear is taking place 
are not always clear, as they may differ much in their manifestations. We 
should therefore watch with the greatest solicitude and examine with the 
greatest care the ear during the course of scarlet fever. The symptoms 
may be active and represented by aural pain and great restlessness. On 
the other hand, there may be no apparent pain, especially in infants and 
young children, who are often unable to indicate the location of the pains 
by which they are affected. In these cases the symptoms may be merely a 
somnolent condition and occasional attacks of fretfulness. 

Treatment. — As soon as an aural complication is detected the treat- 
ment of the naso-pharynx should be begun. The nose and naso-pharynx 
should be kept as clean as possible. The ear should be gently inflated 
by means of a Politzer bag. Pain should be combated by the instillation 
into the ear of a solution of atropine in glycerin and water, and by the 
application of dry warmth. In addition to this, an opiate should, if re- 
quired, be given internally. 

Prescription 80. 

Metric. Apothecary. 

Gramma. 



06 R Atropinae sulphatis gr. i ; 

Glycerini, 

75 Aq. destil aa 3 i. 

M. M. 

Sig. — Three or four drops to be warmed and dropped into the ear once every three 
hours. 



R A tropin a3 sulphatis 

Glycerini, 

Aq. destil 



The congestion should be controlled so far as possible by the internal 
administration of bromide of potassium in small and frequently repeated 
doses. If these measures fail to give relief, and if there is an increase of 
inflammation in the middle ear, as shown by marked swelling and conges- 
tion, especially of the superior posterior portion of the membrana tympani, 
or by a bulging of the membrane, which is seen to be pressed outward by 
the fluid in the tympanum, paracentesis with the knife should be per- 
formed, always with antiseptic precautions and under good illumination. 
In the early stages of congestion a concentric incision carried along the 
superior posterior border of the membrana tympani through the congested 
region, and resulting in free hemorrhage, will often cut short an acute 
process. A free incision in the most prominent portion of a bulging 
membrana tympani, by giving a vent to the contained pus, may result in 
speedy relief from both pain and fever, and justifiably forestall the effort 



SPECIFIC INFECTIOUS DISEASES. 571 

which nature is making to obtain this relief. In the acute congestive 
stage, after incision of the membrana tympani drainage-wicks made of 
dry absorbent cotton should be applied, and covered at their outer end 
with a pad of absorbent cotton filling the concha. These wicks should 
be renewed as often as both the wick and the cotton pad become satu- 
rated. The dressing should be kept strictly aseptic. After the para- 
centesis of the membrana tympani, in suppurative cases the ear should 
be syringed frequently with a weak, warm solution of bicarbonate of soda, 
then carefully dried by means of absorbent cotton, and, after the first few 
days, dressed by the insufflation of powdered boracic acid, while vaseline 
may be applied to the canal and concha to guard against excoriation of 
the skin. 

The after-treatment of the middle ear in these cases in which there is 
no perforation of the membrana tympani should consist in gentle inflation 
by means of the air-douche used in accordance with the evidence afforded 
by hearing-tests and by the objective examinations. In cases in which 
there is perforation of the membrana tympani with continued suppura- 
tive discharge, thorough cleansing should be employed. If under this 
treatment improvement does not soon take place, the patient should be 
referred to an aurist. 

Children are so often rendered deaf by the morbid processes resulting 
from the scarlet fever contagium that it becomes a positive duty for 
the attending physician to watch the ear as carefully in these cases as 
he would watch the heart in a case of rheumatism. In addition to the 
danger arising from a chronic disturbance of the tissues of the ear, 
the rapid extension of secondary infection from the naso-pharynx to the 
middle ear, and thence through the petro-squamosal suture to the cerebral 
meninges, is a series of complications which usually proves fatal. 

The following case illustrates the danger of not treating promptly and 
thoroughly the complication of otitis media in cases of scarlet fever. 



A child two and a half years old had been attacked with scarlet fever and later 
with a complicating purulent otitis. When I saw the child it was lying in a state of 
stupor, apparently induced by pressure on the cerebral blood-vessels of an unusually 
large collection of pus in the middle ear through the petro-squamosal suture. In this 
case rupture had taken place in both tympanic membranes, and the pus was flowing 
in large quantities from the external meatus. The perforations of the tympanic mem- 
branes were, however, very minute, and the cerebral stupor was not relieved until a 
free opening was made in each tympanum and the entire middle ear thoroughly 
syringed out. Although the symptoms of pressure were relieved by these procedures, 
secondary infection of the cerebral meninges had already taken place, and the boy 
subsequently died of an acute purulent meningitis. 

This case warns us that we should not be misled by the idea that a simple flow of 
pus from the auricle is necessarily sufficient to provide a proper exit for collections of 
pus in the middle ear, and that, unless the case is in the hands of an expert aurist, 
cerebral pressure or purulent meningitis is likely to occur at any time. It also illus- 
trates one of the secondary forms of meningitis. 



572 PEDIATRICS. 

Kidney. — Symptoms. — It is very important to detect by means of fre- 
quent analyses of the urine the beginning of either the milder forms of renal 
disturbance or of the more severe forms of nephritis, usually represented 
by that which is called capsular glomerulo-nephritis. If carefully watched 
for. the appearance of albumin will almost always precede the clinical symp- 
toms, and by a still more rigid enforcement of the rules laid down as prac- 
tically governing the treatment, the further development of a nephritis may 
be prevented or at least rendered much less pronounced. It is quite fre- 
quently the case that a suspicion is first aroused of the presence of a 
nephritis either by vomiting or by oedema of the face, especially about the 
eyes, and commonly occurring during the period of desquamation, from 
the eighteenth to the twenty-fourth day. Under these circumstances the 
urine will be found to be diminished in quantity and to contain albumin. 
The daily amount of the urine may be reduced as low as 100 c.c. (3 J- 
ounces), or even lower. The microscopic examination of the urine does 
not differ materially from that which results from the other forms of 
nephritis in their early stages, but later we may possibly find that fatty 
casts are less numerous in the nephritis of scarlet fever, because there is 
less fatty degeneration in the renal epithelium. The earlier in the course 
of the disease the symptoms of nephritis appear, the more severe, as a 
rule, will be its type. The extent of the albuminuria is of less conse- 
quence than the total quantity of the urine. A rapid and extensive 
diminution of the urine is ominous, as it indicates the accumulation of 
nitrogenous waste in the blood and the danger of a resulting uraemia. 
The albumin occurring early in the disease is more apt to be in large 
quantities than when it appears first in the third or fourth week. Hema- 
turia is frequently present in this form of nephritis, but ordinarily of 
itself adds little to the gravity of the disease. The oedema of the face 
may be followed by a rapid involvement of the ankles and legs and at 
times may become general. During the course of a general oedema the 
desquamation is apt to cease, returning on its disappearance. The 
oedema may last for months or may pass away quickly ; it may be en- 
tirely absent, but in such cases the nephritis is almost invariably of a 
light grade. 

At times during the presence of a general oedema serous effusions into 
the pleura may occur. (Edema of the lungs and brain, although rather 
rare, may also take place. Instead of a slow development beginning with 
oedema of the face we may have an acute attack, ushered in by fever,, 
vomiting, headache, oedema, amblyopia, coma, and convulsions. 

Relapses may occur many weeks after an attack of scarlatinal ne- 
phritis, and we should watch the case with the greatest care for several 
months. Although the nephritis of scarlet fever may last for months, it 
has a tendency in children ultimately to disappear, on account of their 
wonderful recuperative powers. It is also rare for the renal disease fol- 
lowing scarlet fever to become chronic. 



SPECIFIC INFECTIOUS DISEASES. 573 

Retinitis and amaurosis at times occur during the progress of the ne- 
phritis in scarlet fever. In these cases of amaurosis it has been noticed 
that, although the loss of sight may be complete, almost always when 
uraemia and amaurosis are coincident there are found no perceptible 
changes in the retina, no congestion of the papillae, no increase of intra- 
cranial pressure, and no intense oedema of the brain. The sight, under 
these circumstances, may be recovered completely. 

The alterations in the glomeruli already spoken of not only cause the 
anuria and the uraemia, but also obstruct the renal arteries, as very nearly 
all the renal blood has to pass through the glomeruli. We find in quite a 
large number of cases of capsular glomerulo-nephritis a rapid hypertrophy 
of the left ventricle. This cardiac complication is not to be confounded 
with the endocarditis which has already been spoken of as secondary to the 
scarlet fever, and which is supposed to be caused by its special poison or 
by the streptococci which has already been described as being present in 
the disease. It is, in fact, not the direct result of the scarlet fever, but is 
secondary to the nephritis, and is, in this sense, tertiary to the scarlet fever. 
We therefore do not find this acute cardiac hypertrophy in the earlier 
stages of scarlet fever, but when a capsular glomerulo-nephritis is once 
established it may take place in so short a period as a week. This rapid 
hypertrophy has usually been observed in children between the ages of 
three and six years, which is of some significance in explaining why this 
hypertrophy should take place so easily. Between the ages of three and 
eight years a physiological hypertrophy of the heart exists, possibly caused 
by a continuance of the aortic narrowing in the neighborhood of the ductus 
arteriosus, and the heart is more readily affected by increased blood- 
pressure at that age. This tendency to change in the cardiac muscles is 
also accentuated by the rapid growth of the organ at this period of life. 
Besides the cardiac hypertrophy we may, at times, have an acute dilata- 
tion of the heart in these cases. This is a serious complication, which 
must be guarded against, and when it occurs must be recognized at once. 
These cardiac complications very frequently recover completely, as it 
is seldom that any extensive changes in the muscles of the heart take 
place. 

Although the occurrence of sugar in the urine during the course of 
scarlet fever is very rare, yet it is well to examine the urine for this ele- 
ment. By taking this precaution it will sometimes be possible to explain 
some otherwise obscure symptoms. Zinn reports a case of glycosuria 
following scarlet fever in a boy four years old who recovered. 

Treatment. — While very little treatment beyond hygienic measures is 
needed for the mild uncomplicated cases of scarlet fever, this can hardly 
be said of the cases that are complicated with severe forms of nephritis, 
for in these we must act promptly and with great judgment. 

We should be careful about using diuretics which might irritate the 
kidney. Citrate of potash is one of the safer diuretics in this complica- 



574 PEDIATRICS. 

tion. In the lighter cases a lemonade made with bitartrate of potash will 
be taken well, and will often quickly increase the quantity of the urine, re- 
duce the oedema, diminish the albumin, and cause a radical change for the 
better. This lemonade may be made by using 4 c.c. (1 drachm) of bitar- 
trate of potash to 473 c.c. (1 pint) of boiling water into which a lemon 
cut in thin slices has been dropped. This quantity, a little sweetened, may 
be drunk in twenty-four hours by a child five years old. 

In severe cases with general oedema and threatening uraemia cathartics 
are rather more certain in their action than diaphoretics and diuretics, 
and are especially indicated when, as is usually the case, constipation is 
present. Podophyllin in doses of 0.006 gramme ( T V grain) may be given 
to a child five years old, and repeated a number of times. It usually acts 
quickly. The compound jalap powder in doses of 0.3 to 0.6 gramme (5 
to 10 grains) may also be given when a rapid and decided derivation by 
the intestine is indicated. 

Having provided for the proper movement of the bowels, if the skin is 
hot and dry, and uraemic symptoms, usually represented by anuria, som- 
nolence, amblyopia, and headache, are present, the hot pack, either wet 
or dry, should be resorted to. I prefer in these cases to have the child 
wrapped in a blanket and placed directly in a tub containing water at a 
temperature of 40.5° to 43.3° C. (105° to 110° F.). The child should be 
kept in the water fifteen or twenty minutes, and even longer if necessary, 
and should then be taken from the wet blanket, enveloped in hot, dry 
blankets and kept in them until the skin has become moist and reaction 
has taken place. While the child is in the bath, milk can be given 
to it, and stimulants if they are indicated by a weak or an intermittent 
pulse. 

In addition to this treatment, hydrochlorate of pilocarpine in doses of 
0.003 gramme (-^ grain) should be given by the mouth to a child of two 
years, and subcutaneously, if desired, to a child five years of age. In 
the cases of threatening uraemia, convulsions sometimes appear quite 
suddenly. Under these circumstances enemata of hydrate of chloral, 0.3 
to 0.6 gramme (5 to 10 grains) dissolved in water, are of value in con- 
trolling the nervous phenomena. A combination of bromide of potash and 
hydrate of chloral can also be used as in the following prescription : 

Prescription 81. 
Metric. Apothecary. 

Gramma. 

R Chloral hydrat 7 

Potassii brom 15 

Aq. destil 90 

M. M. 

Sig. — 3.75 c.c. (1 drachm) in 30 c.c. (1 ounce) of warm water : to be given by enema, 
and repeated in half an hour if needed. 



5 R Chloral hydrat 3 ii ; 

Potassii brom giv ; 

Aq. destil ^ iii. 



Where the ascites is extreme, paracentesis abdominis is often of great 
value, not only in relieving the pressure, but also in increasing the action 



SPECIFIC INFECTIOUS DISEASES. 575 

of the diuretic, which, perhaps, before was not acting freely. Digitalis is 
a valuable remedy especially adapted to the treatment of the nephritis of 
scarlet fever and to that of the cardiac changes which result from it. By 
the administration of this drug the flow of urine is increased. It is best 
given in the form of a freshly prepared infusion, in teaspoonful doses 
every four hours to a child five years old. Diuretin, 0.3 gramme (5 
grains), dissolved in water and given two or three times in the twenty- 
four hours, has proved of considerable value in mv cases, and is ap- 
parently harmless. 

Joints. — Symptoms. — An acute inflammation of the joints, usually the 
larger ones, is not infrequently met with during the course of scarlet 
fever. It is more frequent in adults than in children, and usually occurs 
at the end of the first week (Marsden). This acute synovitis is at times 
apparently either due to or closely connected with rheumatism, and may 
be accompanied by endocarditis and pericarditis. The latter disease is, 
however, rarely met with unless in the later stages of scarlet fever in 
cases in which nephritis has developed. These rheumatic cases are 
usually controlled by the administration of salicylic acid. As a rule, 
they are not of long duration, and if effusion takes place in the joints 
it is serous, does not become purulent, and does not give an especially 
serious prognosis. True rheumatic synovitis in convalescence is very rare. 

In connection with these cases, when uncomplicated or when the 
heart is also affected, chorea has sometimes arisen as a complication. 

A more severe form of synovitis, apparently caused by sepsis, may 
also occur during the course of scarlet fever. The effusion in the joints 
in these cases may become purulent and lead to serious and permanent 
disorganization of the tissues and often to death from general septic 
infection. 

Besides these acute inflammations of the joints a chronic process at 
times arises, appearing, as a rule, very late in the disease or subsequent 
to it by many months. This inflammation is tubercular in character, and 
affects with especial frequency the hip and knee. Although tubercular, it 
seems to be a late result of the original toxic effect of the micro-organ- 
isms of or secondarily connected with the scarlet fever contagium. 

In addition to these more common complications of scarlet fever a 
number of secondary infections are at times met with. Thus, cases of 
purpura following or complicating scarlet fever have been reported, and 
are usually fatal. 

Bruck reports three cases of myositis of the large muscles following 
scarlet fever, the symptoms being pain, tenderness, and increase in the 
size of the muscles. 

The following case represents one of the milder forms of what was probably cap- 
sular glomerulo-nephritis, and the effect of rest in the treatment of the disease. 

A girl, five years old, was attacked by scarlet fever of the benign form and very 
mild in its character. After the usual prodromal symptoms the efflorescence appeared 



576 PEDIATRICS. 

and ran its course, and desquamation became established. At the end of the second 
week, and while the desquamation was still present, the child seemed so well that it 
was allowed to be dressed and about its room. It was also allowed to have its usual 
food, which included a considerable amount of meat. 

On January 4 the child was very irritable during the day and passed her urine 
involuntarily in the forenoon. During the afternoon she was feverish, and passed 
frequently small amounts of urine. That night she slept well, but on awakening on 
the morning of January 5 she seemed dull, and was said to be feverish and to have 
little appetite. 

On January 6 the record stated that she had passed only 90 c.c. (3 ounces) of 
urine in the twenty-four hours. She seemed tired and languid, and there was an 
cedematous condition of the eyes and upper part of the face. She had one normal 
movement of the bowels. 

On January 7 the total amount of urine passed in the twenty-four hours was 480 
c.c. (16 ounces). She was given infusion of digitalis and cream of tartar water on 
this day, and placed on a diet of milk. 

On January 8 she seemed better, and passed 480 c.c (16 ounces) of urine in the 
twenty-four hours. She was then allowed to have an increase in her diet, consisting 
of various kinds of broth. An examination of the urine by Professor E. S. Wood on 
this day gave the following result : . 

Color Kather pale. 

Reaction Acid. 

Urophsein Diminished. 

Indoxyl Increased. 

Urea Diminished. 

Uric acid Increased. 

Albumin Considerable trace. 

Sugar Absent. 

Bile-pigments Absent. 

Specific gravity 1009. 

Chlorides , Almost absent. 

Earthy phosphates . . . Diminished. 

Alkaline phosphates. .Diminished. 

Sediment Slight in amount ; consisted chiefly of normal blood-globules, a 

few renal cells, and a few hyaline, fibrinous, blood, and epi- 
thelial casts. The blood-globules and the casts were normal 
in appearance. 

In regard to this examination Professor Wood remarks that the important features 
of the urine were its dilution, the great diminution in the normal salts, especially in 
the chlorides, the considerable trace of albumin, and the blood and casts. The 
normal character of the blood-globules and the comparatively small number of the 
casts seemed to show that only a small portion of the kidney was affected. At the time 
of the great diminution in the quantity of the urine the tubules were probably nearly 
completely blocked up. The low specific gravity and the great diminution of the 
urea and chlorides seemed to indicate that it would need but little additional irritation 
to produce a marked nephritis. The condition appeared to be one of a mild nephritis. 

The general symptoms presented by the child and the disturbance of the kidney 
shown by the examination of the urine made me advise that she should be kept in 
bed in a warm room and placed on a diet exclusively of milk. A warm bath was to 
be given once or twice daily until a larger amount of urine was passed, and 4 c.c. (1 
drachm) of infusion of digitalis administered four times in the twenty-four hours. 

On January 9 the total amount of urine passed in the twenty-four hours was re- 
duced to 90 c.c. (3 ounces), and the child was nauseated and vomited a number of times 
during the day. 



SPECIFIC INFECTIOUS DISEASES. 577 

On January 10 she was reported to have had a very restless night and to have been 
very much excited on awakening. She had no pain anywhere. Her face continued to 
be cedematous. The total amount of urine passed in the twenty-four hours was 240 c.c. 
(8 ounces). She perspired slightly, and had one large, loose dejection. She so abso- 
lutely refused to take milk that she was given 103 c.c. (3£ ounces) of beef-juice, which 
was all the nourishment that she took on this day. 

On January 11 the face was more cedematous, and she was languid. She had two 
large, loose, offensive dejections from the bowels, and complained of a burning sensa- 
tion in the rectum at the time of the movements. The total quantity of urine was 300 
c.c. (10 ounces). On this day she was finally persuaded to take milk, and no other 
food was given to her. 

On January 12 the child seemed brighter and the face was not so much swollen. 
The total amount of urine in the twenty-four hours increased to 540 c.c. (18 ounces). 
Complete recovery took place in three and one-half months from the beginning of the 
attack. 

During the course of her sickness various attempts were made to increase her diet 
more quickly and to allow her to be dressed and about the room, but each time when 
this was done she showed symptoms which pointed towards the presence of a renal 
complication, such as a swelling of the eyes and face and a rise of temperature, with 
resulting nausea and loss of appetite. 

This case shows how careful we must be for many weeks and even months to con- 
trol the temperature of the room, the amount of exercise, and the kind of food, when 
nephritis has complicated a case of scarlet fever. It also shows how entire recovery 
may take place even when the renal irritation is pronounced and unusually prolonged. 

Fig. 182, on page 855, represents a case of scarlet fever complicated 
by a probable capsular glomerulo-nephritis and a resulting cardiac enlarge- 
ment. The following is a record of the case : 

A boy, seven years old, entered the hospital on July 28. His mother was living 
and well, and stated that his father died of Bright' s disease. The child was said to have 
been well until five and a half years old, when he had an attack of scarlet fever, mild in 
form and not accompanied by any severe symptoms. In the latter part of the attack 
his temperature rose and he began to have dyspnoea and dropsy. Since that time he 
had been slowly but steadily growing worse. He had extensive oedema of the face, 
chest, arms, abdomen, and legs. He was somewhat cyanotic, and his breathing was 
so much affected that he was unable to lie down, the orthopncea compelling him to be 
supported in a semi-recumbent position. There were a slight puffmess about both eyes 
and a yellow tinge of the conjunctivae. The lips and tongue were cyanotic. The ex- 
tremities were cold to the touch, and the skin pitted readily on pressure. The skin of 
the whole body was dry and harsh and in certain portions covered with fine scales. On 
the inner side of the left leg and on the outer side of the right leg were some old scars, 
apparently resulting from a previous scarification performed for the reduction of the 
anasarca. In addition to the cedematous condition of the walls of the abdomen, a 
distinct fluctuation was found on palpation. An examination of the lungs showed that 
there was dulness over both bases behind, and over these areas of dulness, as well as 
over the whole front of the chest, fine moist rales could be heard, indicating an 
cedematous condition of the lungs. The heart's impulse was most distinct in the sixth 
interspace a little outside of the mammillary line. The area of cardiac dulness extended 
from the second rib on the left to 2.5 cm. (1 inch) to the right of the sternum, in an 
area corresponding to the third interspace and fourth rib. The dulness then extended 
to the left across the sternum to a point 2.5 cm. (1 inch) outside of the mammillary 
line and as low as the sixth interspace, corresponding to the cardiac impulse. A loud 

37 



578 PEDIATRICS. 

systolic murmur could be heard over the region of the cardiac impulse, and was trans- 
mitted so that it could be heard in every part of the thorax. The total amount of 
urine in twenty-four hours varied from 900 to 1050 c.c. (30 to 35 ounces). An analysis 
of the urine gave the following results : 

Color Darker than normal. 

Specific gravity. .1013. 

Reaction Acid. 

TJrophnein Diminished. 

Indican Increased. 

Chlorides Diminished. 

Albumin ■§ per cent. 

Sugar Absent. 

Sediment Yery slight and flocculent. Microscopic examination showed numer- 
ous short hyaline and granular casts of medium diameter and 
occasionally of small diameter ; an excess of renal epithelium ; con- 
siderable abnormal blood ; an occasional white corpuscle ; one or 
two blood-casts, many hyaline and granular casts, with one or more 
renal cells adherent ; occasional fatty renal cells and casts with a 
few fat-drops adherent. 

July 29 he was unable to lie down with comfort, on account of dyspnoea arising 
from an accumulation of fluid in the abdomen. The legs were also very much swollen 
and oedematous. His face was somewhat puffy. The cyanosis was marked and the 
child had considerable dyspnoea. 

Paracentesis of the abdomen was performed, and after 480 c.c. (16 ounces) of clear, 
yellowish fluid were removed the cyanosis and dyspnoea were decidedly diminished. 

The treatment was absolute rest, so as not to tax the muscles of the heart more 
than possible, hot baths to increase the action of the skin, laxatives to relieve the con- 
gested condition of the kidneys, and non-irritating diuretics, such as citrate of potash 
and digitalis. 

For the next few days after paracentesis of the abdomen the child improved 
greatly, the dyspnoea ceased, the urine became of a better color and increased in 
amount, the cyanosis grew less, and, although the pulse was still small and feeble, the 
child showed great general improvement. In the course of a month the oedema was 
so much reduced that the child looked like a different person. He was able to lie 
down with comfort, slept well, his appetite returned, and at one time he could even 
be moved about the ward in a wheel-chair. Some weeks later the cardiac symptoms 
returned, and he again began to have oedema and ascites, cyanosis and orthopnoea. 
The symptoms were mostly those of a crippled heart. 

On September 8 the oedema increased, and the urine was reduced to 450 c.c. (15 
ounces). Diuretin was given in doses of 0.6 gramme (10 grains), which increased the 
flow of urine to 1230 c.c. (41 ounces). The diuretin given in these doses once or twice 
a day for some time continued to act successfully. 

In October the action of the heart grew still weaker, the oedema of the lungs in- 
creased, and, although there had been a general improvement, the child grew progres- 
sively weaker during November. Early in December he was attacked with vomiting, 
had a weak and rapid pulse, gradually failed in strength, and on the 21st of December 
died suddenly. No autopsy was obtained. 

MALIGNANT FORM OF SCARLET FEVER. 

The malignant form of scarlet fever is almost without exception fatal, 
and is very rare in comparison with the benign form. Malignant scarlet 
fever appears to attack those individuals who have a predisposition to be 



SPECIFIC INFECTIOUS DISEASES. 



579 



C PI ART 22. 



profoundly affected by the scarlet fever contagium. In these cases we see 
healthy children attacked with intense headache, high fever, delirium, 
sometimes coma, and death follows usually in two 
or three days, the course of the disease being un- 
affected by treatment. In these cases, however, the 
anti-streptococcus serum should be used, as it has 
not yet been proved that it may not arrest the dis- 
ease. A case of this kind was seen by me in con- 
sultation with Dr. Emerson, of Concord, and repre- 
sents the conditions which are present in these cases 
of malignant scarlet fever. 

A girl, eleven years old, was perfectly well and strong and 
had no other diseases up to January 10. In the middle of the 
day she felt very ill and vomited. Her pulse was 150, tem- 
perature 40.2° C. (104.5° F.). The pharynx and tonsils were 
much reddened, but there was no exudation or membrane to 
be seen. An efflorescence of a scarlatinal type appeared on the 
chest in the afternoon. The vomiting continued through the 
night and up to the morning of January 11. The child was 
conscious, but dull. The pulse was 150, and the temperature 
was 40.5° C. (105° F.). At 4 p.m. the face became puffy, and 
the efflorescence was well marked on the body and extended to 
the extremities. The child was wandering and stupid, and the 
temperature rose to 42.2° C. (108° F.). The extremities be- 
came livid, and the vomiting began again. At 6.30 p.m. the 
temperature, after the internal administration of various reme- 
dies, was found to be 41.6° C. (107° F.), and at 10 p.m. 41.1° 
C. (106° F.), and the pulse 160, weak and difficult to count. 
At 6 a.m. on the 12th. within forty-eight hours from the appear- 
ance of the first symptoms, the child died 

The case was a perfectly hopeless one from the beginning, 
as every method of treatment which could be thought of was 
tried and proved absolutely fruitless. Tub bathing with water 
at different temperatures, and finally sponging with ice-water, 
had no effect whatever on the temperature or the general 
symptoms. 

Chart 22 shows the temperature from the time of the attack to within a few hours 
before death. 



JDajfs ofDisease, 


F 


! 


2 


3 


c 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NOBML 


M E 


M E 


u 


4 1. .6° 

41.1° 

40.5° 

40.0° 

39.4 6 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 

35.0° 




/ 


V 




/ 






/ 


































1 












97° 

96° 

95° 
150 
140 
130 
120 
110 
100 

90 

80 

70 

60 


















=L 




V 


\l 


to 

_J 

CL 






































1 



















Malignant form of scarlet 
fever. Girl, 11 vears old. 



MEASLES. 

Measles (rubeola) is an acute infectious disease, supposed to be caused 
by a specific micro-organism, and characterized by lachrymation, photo- 
phobia, coryza, cough, a papular efflorescence, and a slight desquamation. 

Etiology. — The micro-organism which produces measles has not yet 
been determined. It is supposed to find its vehicle in the tears, and in 
the secretion of the throat and nose, and possibly to exist in the blood. 
Its tenacity for clothing, thus continuing as a fresh source of infection, is 
mild in comparison with that of scarlet fever. It is very infectious, and 
in some communities is at times exceeding: fatal. This was the case in 



580 PEDIATRICS. 

the epidemic of 1873 in the Fiji Islands, where it had not occurred for a 
long time ; it spread rapidly, and caused two thousand deaths, of which 
sixty-seven per cent, were in children under five years of age. The high 
mortality in measles is, as a rule, not caused by the measles itself, but by 
its complications. The epidemics of measles spread rapidly and appear 
to have an element of periodicity. This has been well exemplified in 
Boston, in the crowded districts at the North End, where in certain years 
large numbers of children are affected, and where in the succeeding years 
the disease appears only sporadically. Measles can occur three or four 
times in the same individual : this recurrence was one of the peculiar fea- 
tures of the epidemic in Boston in 1880. It may attack young infants, but is 
rare under six months. After the sixth month, and especially during the 
first year, the susceptibility to the disease is increased, and we meet with 
the greatest number of cases between the first and the fifth year. The 
susceptibility to measles appears to lessen as puberty is approached. It 
is somewhat rare in adult life, although the fact of its attacking large 
numbers of adults was also a peculiarity of the epidemic of 1880 in 
Boston. 

The contagium apparently passes from one individual to another after 
a very short exposure, and often without any direct contact, as by trans- 
mission through clothing or by the hands. It is most infectious in the be- 
ginning of the attack, and the infection may be transmitted three or four 
days before the efflorescence appears on the skin. There seems to be 
much less liability for the transmission of the disease during the stage of 
desquamation than is the case in some of the other exanthemata, such as 
scarlet fever and variola, the means of transmission corresponding more 
to that of varicella. The following case illustrates the high degree of the 
infection' in the early stages of measles. 

A boy who was in my ward at the Children's Hospital was attacked with scarlet 
fever. I had him removed to the contagious ward and placed under the care of a 
special nurse, who had orders to carry out the most precise antiseptic treatment. The 
directions to the nurse were that she should apply an ointment to the child, rubbing 
it into the skin thoroughly from the head to the feet twice daily. The child was also 
to be bathed twice daily with a solution of corrosive sublimate, 1 to 10,000. The 
nurse was cautioned not to allow her clothes to touch the boy's bed. 

During the early stage of this boy's desquamation a second boy, who occupied the 
bed in the general ward next to the bed from which the first boy had been removed, 
was attacked with sore throat, vomiting, and fever. I had already paid my visit for 
the day, and my house officer, thinking the case was probably one of scarlet fever con- 
tracted from having been in such close proximity to the bed from which the first boy 
was taken, had the second boy removed to the contagious ward and placed in the 
same room with the first boy. On the following morning I found that the second boy 
did not have scarlet fever, but had measles. I immediately had the second boy re- 
moved to another room, and he was carefully watched for a week, supposing that 
having passed the night with the first boy, who was in the most infectious stage of 
scarlet fever, he might have contracted scarlet fever. A week passed, and he evidently 
had escaped infection by the scarlet fever contagium. 



SPECIFIC INFECTIOUS DISEASES. 581 

Ten days later the boy who had scarlet fever was attacked with measles, pre- 
sumably contracted during the night from the boy who was his room-mate in the early 
stage of his attack of measles. 

These two cases apparently show — first, that scarlet fever, even during its most 
infectious stage, can in some cases be prevented from spreading by thorough and 
constant disinfection ; secondly, that measles is highly contagious in its early stages. 

Pathology. — Beyond the morbid conditions which appear on the skin 
and on the mucous membrane of the throat, there is no especially charac- 
teristic pathology of measles. 

Neumann has studied the pathology of the skin in measles by means 
of specimens Avhich were hardened in a dilute solution of chromic acid 
and colored with carmine, hematoxylin, and picro-carmine. The patho- 
logical changes were found to be almost entirely confined to the glands 
of the skin and to the blood-vessels. About the walls of the blood- 
vessels, principally in the upper layers of the cutis, were found collections 
of round cells which in crowded masses surrounded the loops of the 
blood-vessels even in the papillae. The blood-vessels themselves were 
dilated and full of blood. The coils of the sweat-glands, as well as the 
excretory ducts, were enveloped in accumulations of round cells, while 
the neighboring tissues were filled with these cells. These collections of 
cells were always situated outside of the walls of the glands. The seba- 
ceous glands presented like changes. The hair-follicles showed rounded 
protuberances which corresponded to the points of insertion of the erec- 
tores pilorum, and which were probably caused by contraction of these 
muscles. In the muscles themselves there were to be found, behveen 
the cells proper of the muscular tissue, scattered round cells, which 
showed the participation of the muscular tissue in the inflammatory pro- 
cess. The hair-follicles, in the same manner as the sweat-glands, were 
seen to be surrounded in their entire length by collections of round 
cells, which were more numerous in the lower than in the upper part 
of the skin. We therefore see that in measles the pathological process in 
the skin affects chiefly the blood-vessels and glands, while the tissue proper 
of the skin, as well as of the epithelium, presents no marked changes. 

From the fact that in measles the pathological processes of the disease 
are situated more particularly around the blood-vessels and cutaneous 
glands, it may be assumed that the infectious material of the malady, 
whatever its nature, is eliminated from the system through these chan- 
nels. 

In addition to the pathological lesions which occur in the uncompli- 
cated cases of measles, there is almost always associated with the catar- 
rhal condition of the mucous membrane of the upper air-passages a 
catarrh of the larger bronchi. One of the most common complications 
of measles is pneumonia ; this is usually a broncho-pneumonia, lobar 
pneumonia being comparatively rare. 

In some cases an inflammation of the smaller bronchi accompanied 



582 PEDIATRICS. 

by pulmonary collapse occurs. The bronchial glands are apt to be 
swollen if the secondary infection is a severe one. According to Osier, a 
swelling of Peyer's glands is not uncommon, and may be accompanied by a 
hyperaemic condition of the mucous membrane of the gastro-enteric tract. 

Although a secondary infection of the ear has been considered rather 
distinctive of scarlet fever, this complication has in my experience arisen 
also quite frequently in measles. When the ear is affected in measles 
there is a congestion of the middle ear. When the onset of the prelimi- 
nary congestion occurs in connection with the inflammation of the nasal 
and naso-pharyngeal mucous membrane, it consists of a simple, general, 
acute congestion of the middle ear, accompanied in the beginning with 
serous exudation, and later with a rapid thickening of the membrana 
tympani in connection with the inception of the suppurative process. 
When, on the other hand, the preliminary congestion is coincident with 
or follows the efflorescence on the face, the congestion is primarily in the 
upper portions of the membrana tympani as the result of a suspension of 
vasomotor inhibition. Under these conditions there is a congestion of 
the manubrial plexus, of the superior and posterior portions of the mem- 
brana tympani, and of the corresponding portions of the inner end of the 
external auditory canals. 

In addition to this more common condition, a general congestion of 
the membrana tympani is found during the stage of efflorescence, and is 
likely to be more severe in its type than that which occurs during the 
prodromal stage of measles. 

The inflammation of the middle ear accompanying measles is more 
likely than is scarlet fever to leave behind such trophic changes as thick- 
ening of the tympanic mucous membrane with the formation of adhesions. 

During an attack of measles, and subsequent to it, the tissues show an 
especial vulnerability to infection by the tubercle bacillus. The tuber- 
cular infection may be represented by the lesions of a general miliary 
tuberculosis or by those of especial tissues, such as of the cervical and 
bronchial glands, the joints, the ear, and, most commonly of all, the lung. 
In the latter instance the lesions are usually those of a tubercular broncho- 
pneumonia. 

Incubation. — The time of the incubation of measles may vary very 
much, and may cover a period of two or three weeks ; the usual time, 
however, is ten days. 

Symptoms. — Prodromata. — The prodromal stage varies in length, but, 
reckoning ten days as the usual time for the stage of incubation, the pro- 
dromal stage may be considered to last from two to three days, and in some 
cases four days. In this stage we have in typical cases of the disease symp- 
toms distinctive of measles. The invasion is characterized by severe ca- 
tarrhal conditions affecting the nose (coryza), the eye (lachrymation), and 
the throat and upper air-passages (cough). In the first twenty-four hours 
the temperature rises to 38° or 39° C. (100.4° or 102.2° F.), and often to 



SPECIFIC INFECTIOUS DISEASES. 583 

40° C. (104° F.). The height of the temperature on the first evening is a 
fair indication as to the severity of the coming disease. Thus, a tempera- 
ture of 40.5° C. (105° F.) indicates a severe case. An important point to 
be noticed regarding the prodromal symptoms is that after the first twenty- 
four hours there is in a large number of cases a remission in the tempera- 
ture, which goes down, perhaps, to 37.5° or 37° C. (99.5° or 98.6° F.), 
and remains down for about twenty-four hours, when it again rises. The 
cough, coryza, and lachrymation, which appear early in the prodromal 
stage, do not abate, but rather increase, during this remission of the tem- 
perature. This is an important point to remember, as the child who 
seems quite sick and loses its appetite while the temperature is high during 
the invasion of the disease, seems brighter and has a return of appetite on 
the second day when the temperature is lower. This peculiarity of the 
prodromal stage is often misleading both to the parents and to the physi- 
cian, who, because the child appears so much better, are led to believe 
that one of the infectious diseases is not developing. In infants and young 
children the prodromal stage may begin with a convulsion, but this is un- 
usual, and if it occurs it is not, as a rule, particularly severe, and does not 
necessarily make the prognosis more grave. Headache in the prodromal 
stage is quite frequent ; vomiting is rather rare. The tongue is usually 
furred, and the mucous membrane of the throat towards the end of the 
second day, and before the efflorescence has appeared on the skin, shows 
a condition which is very similar to that which is about to appear on the 
skin. These lesions, which are especially pronounced on the soft and the 
hard palate, are represented by papules or macules of a dark-red and later 
purplish-red color, of different sizes, and considerably larger than the 
punctate macules which were described in connection with the throat in 
scarlet fever. These papules in certain cases are arranged crescentically, 
and may sometimes be found to have coalesced in some parts of the fauces. 
The mucous membrane between the lesions is comparatively normal in 
color, although there may be a slight hyperemia of the entire throat. This 
hypersemia, however, is not nearly so intense as is seen in the throat in 
scarlet fever. Forchheimer states that the exanthem in measles begins 
upon the soft palate from thirty-six to forty-eight hours before the efflo- 
rescence, in the form of purplish or bluish papules arranged crescentically, 
extends over the mucous membrane of the cheeks, and is accompanied by 
a bluish color of the tongue. The exanthem is at its maximum with the 
beginning of the efflorescence, and may take as long as three or four days 
to disappear. 

In addition to the efflorescence in the throat, Koplik has described cer- 
tain spots on the mucous membrane of the cheeks which appear during 
the prodromal stage. He describes these spots as minute bluish-white 
specks in the centre of a reddish areola. Widowitch has found them in 
86.6 per cent, of cases of measles, in 8 per cent, of cases of rubella, and 
in less than 1 per cent, of other cases. 



584 PEDIATRICS. 

After the remission of the temperature, on the second day, the temper- 
ature again rises on the third or fourth day. 

Efflorescence. — At the end of the third day or at the beginning of the 
fourth day — that is, the thirteenth or fourteenth day from the time when 
infection took place — an efflorescence appears on the skin. The efflores- 
cence usually reaches its maximum in about thirty-six hours, this being a 
more constant number than the other figures ; that is, it is about the fif- 
teenth day from the date of infection. The stage of incubation is rather 
more constant than the stages of prodrome and efflorescence, the latter 
two varying as to their length, but together amounting to five or six days. 

When the efflorescence appears on the skin it consists commonly of 
small macules or papules on a slightly reddened base, which first appear 
on the face. As the disease progresses, these lesions extend to the neck 
and chest, and in the latter locality are, especially in the beginning, of a 
delicate pink color, the form of distribution in some cases being crescen- 
tic. The efflorescence then rapidly extends to the rest of the body and to 
the extremities. It is usually more pronounced on the face, where the 
papules are apt to coalesce, and where an cedematous condition of the 
tissues, especially around the eyes and nose, usually occurs. The eyes 
are swollen and partially closed, and the conjunctivae are reddened. Pho- 
tophobia at this time is pronounced. The efflorescence may also appear 
on the scalp. It remains well marked for from one to two days, and 
while it is at its height the temperature reaches its maximum, and remains 
high for two or three days, corresponding to the intensity of the efflo- 
rescence. It then rapidly falls, and reaches the normal point in about 
two days more, — that is, there often appears to be a distinct crisis in the 
disease. During the period of efflorescence, when the temperature is still 
raised and the efflorescence is at its maximum, it is usual to have, in addi- 
tion to the symptoms of cough, coryza, and lachrymation, a slight dis- 
turbance of the intestines, represented by small, frequent, loose discharges, 
apparently arising from irritation of the rectum and descending colon. 
This condition is seldom a serious one, and no especial attention need be 
paid to it unless it should continue for some days, or after the maximum 
of the temperature and efflorescence has been passed for a day or two. 

Desquamation. — The desquamation is usually furfuraceous in charac- 
ter, — that is, the epithelium is cast off in fine flakes, and is thus distin- 
guished from the large lamellar flakes occurring during the period of 
desquamation in scarlet fever. The desquamation begins in the order in 
which the efflorescence came out, — namely, first on the face and later 
on the chest. The furfuraceous character of the desquamation is espe- 
cially noticeable on the sides of the nose. The disease usually runs its 
entire course in three weeks. 

Diagnosis. — In order to understand how difficult it sometimes is to di- 
agnosticate measles, we must recognize that it is one of the most variable 
diseases with which we have to deal. During epidemics of undoubted 



SPECIFIC INFECTIOUS DISEASES. 585 

measles cases arise which differ materially from the disease as it appears 
in its typical form, yet these cases, by producing the typical form in other 
individuals, prove that they are all caused by the same contagium. In 
like manner certain epidemics may be characterized by irregular forms of 
the disease, and, as true measles can occur a number of times in the 
same individual, the recognition of a sporadic case is often impossible. 
As in other diseases of the skin, we should recognize measles not by any 
particular dermal lesion, but by the peculiarities of the prodromal symp- 
toms, the general course and location of the efflorescence, the time of the 
maximum of the efflorescence and temperature, and the character of the 
desquamation. Thus, a prodromal stage of three or four days, charac- 
terized by catarrhal symptoms of the eyes, nose, and upper air-passages, 
by the presence of Koplik's spots in a large majority of cases, and a papular 
efflorescence appearing first on the face, differentiates the disease from 
variola, varicella, and scarlet fever. 

Prognosis. — The prognosis of measles, as a rule, is good, but this 
depends almost entirely upon whether the disease is free from or accom- 
panied by complications. 

Treatment. — The treatment of measles is essentially symptomatic. 
There is no known means of producing immunity to the disease or of 
shortening its course. It is a self-limited disease, and the treatment 
should be directed towards the protection of the organs which are most 
likely to be attacked by complications. Bearing in mind that the eye, 
the nose, and the throat are affected in the prodromal stage, that later the 
skin is in a very sensitive condition, and that the lung is frequently the 
seat of some complication, we should direct our treatment ' especially to 
the care of these organs. 

The child should be placed in a room kept at an equable temperature, 
20° to 21.1° C. (68° to 70° F.), and well ventilated. The room should be 
darkened, and the eyes should be protected from light during the whole 
course of the disease. Unless this precaution is taken, the eyes are often 
seriously affected for many months after the measles itself has disap- 
peared. The child should be kept in bed until the temperature has been 
normal for a few days, the efflorescence has faded entirely, and the des- 
quamation has almost ceased. 

The diet during the period of the height of the temperature should 
be soup, milk, and bread. Later, when the temperature is normal and 
desquamation has begun, the child can gradually have its diet increased, 
until by the third week from the beginning of the attack it is having its 
usual food. 

The cough, which is very troublesome at times, does not, as a rule, 
require any special treatment, as it will of itself in most cases pass off in 
a few clays. While it continues it can be treated Avith some simple mix- 
ture, such as camphorated tincture of opium in cold water in doses of 
0.3 to 0.6 c.c. (5 to 10 minims), to allay the irritation in the throat. 



586 



PEDIATRICS. 



For the irritation of the nose, atomizing the nares with some simple 
refined oil, such as oleum petrolatum album, is useful. During the inva- 
sion of the disease, however, these catarrhal symptoms are exceedingly 
difficult to control by any treatment whatever. 

As at times there is great irritation of the skin during the period of 
efflorescence, a powder (such as Prescription 62, page 366) should be 
applied thickly to the entire body and limbs. In place of the powder 
some simple ointment, such as petrolatum, may prove to be more soothing. 

As a rule, the child should be kept in an equable temperature for at 
least three weeks, and at the end of that time, if the desquamation has 
ceased, it may be allowed to go out of its room, and out of the house a 
few days later in pleasant weather. For several months, however, it 
should be carefully protected from sudden changes of atmosphere, as the 
catarrh of the air-passages is so likely to leave them in an extremely 
sensitive condition that a very slight irritation may cause a recurrence. 

Before the child is allowed to leave its room it should be thoroughly 
bathed from head to foot in hot water. Although the contagium of 
measles has not the same tenacity for clothing as the contagia of variola 
and scarlet fever, yet the room should be thoroughly disinfected after the 
child has left it. This can be done in the same way as described in 
speaking of scarlet fever ; but the extreme precautions taken in the 











CHAET 


23. 












Dai/s of Disease 




F 


I 


2 


3 


4 


5 


6 


7 


8 


9 


10 


c 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORML 
TEMP 
98° 

97° 

96° 
95° 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


4*16° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37 2° 
37 0° 

36 6° 

36.1° 
35.5° 
35.0° 1 


















































i / 
















/ 


V 


V 


































/ 
























































L-, 


... 


— 


..... 


— 





s 










































































1 



Typical measles. 

latter disease are not considered necessary for the prevention of the ex- 
tension of measles. If the carpet had not been removed when the 
child was put into the room; it can be taken from the house and 
thoroughly cleansed before it is brought back. The bedclothes and 



SPECIFIC INFECTIOUS DISEASES. 



587 



everything that can be washed should be thoroughly boiled. The room 
should be cleansed and the windows allowed to remain open for several 
clays, as fresh air is one of the best means of eradicating the micro-organ- 
isms connected with the exanthemata. 

Chart 23, page 586, shows the temperature as it usual 1 }' occurs in the 
typical and regular form of measles. 

The following case and figure represent a typical case of measles : 



Fig. 127, 



A girl, six years old, after an incubation of ten days, was attacked with lachryma- 
tion, coryza, cough, and a temperature of 39.4° C. (103° F.). On the second day 
from the beginning of the invasion the temperature fell to 
37.7° C. (100° F.). On the third day it rose again, and on 
the fourth day the temperature rose to 40° C. (104° F.). and 
an efflorescence, papular in character, appeared on the face 
and extended to the neck and thorax. The disease as rep- 
resented in the picture is at the height of the stage of 
efflorescence on the fifth day from the beginning of the pro- 
dromal symptoms and the fifteenth from the date of the in- 
fection. It shows the swollen condition of the eyes, nose, 
and entire face. The photophobia was extreme, and there 
was considerable lachrymation, a continual, short, dry cough, 
and extensive coryza. The papules coalesced on the face, 
and were of a darker color than the widely separated lesions 
on the chest. 

Plate VIII., facing page 564, represents a boy, eight years 
old, who was at the height of the efflorescence of an attack 
of measles. 

The different stages of the typical lesions of measles are 
represented on his face and chest. The conjunctivae are 
reddened, and the eyes, nose, and lips are swollen. The 
efflorescence in this case ran a very rapid course, beginning 

on the face in so intense a form that the desquamation had already appeared, although 
the efflorescence on the chest was in a much earlier stage of development. The 
papules and macules had coalesced on the cheeks and chin, while they still appeared 
as large, deeply reddened lesions on the forehead. On the chin and neck were areas of 
normal skin appearing like white blotches, their boundaries determined by the clusters 
of papules. On the side of the nose there was a slight desquamation, which had the 
furfuraceous character already described as typical of measles. On the chest the 
papules and macules were much smaller in size, of a much lighter color, and in some 
places had assumed a crescentic shape. 




Typical condition of the 
face in measles. 15 days 
from infection. Female, 6 
years old. 



Variations in Type of Measles. — Measles during epidemics and in 
sporadic cases varies much in its type, and presents great differences in 
its prodromal stage, in its dermal lesions, in its desquamation, and in its 
entire course. Through a lack of appreciation of this fact the diagnosis 
of other diseases, such as rubella and various forms of erythema, is con- 
tinually being made when, in fact, the disease represents one of the 
more unusual forms of measles. If these variations in measles were 
better understood, we should not find the disease rubella so often diag- 
nosticated. 



588 PEDIATRICS. 

At times the stage of incubation of measles varies considerably. It 
may even be extended from the usual ten days to twenty-one days. 

Instead of the usual prodromal stage, certain cases during epidemics 
of undoubted measles show few, if any, prodromal symptoms. 

In addition to the usual catarrhal symptoms, in some cases there are 
vomiting and sore throat. Again, instead of a considerable elevation, 
the temperature may be scarcely above the normal degree. In addition 
to the other variations in the course of the prodromal stage of measles, 
cases have been noticed during epidemics in which the catarrhal symp- 
toms were absent. Epistaxis of a mild form, and not apparently con- 
nected with the more severe types of hemorrhage, is sometimes met 
with. I have seen it only occasionally. 

The efflorescence, which in the typical cases usually consists of pap- 
ules, or vesicles and papules, may vary so as to simulate closely a common 
erythema, constituting the form called Icevis, or may closely simulate a 
papular erythema. Again, the efflorescence may in certain cases be rep- 
resented by minute vesicles or milia, characterizing the form called mili- 
arius. Any of these forms may be confluent, but, as a rule, only upon the 
face. 

There is another form of efflorescence which occurs in measles, which 
is rare, and of a more serious nature than the common benign forms 
which are met with ordinarily. This is called the hemorrhagic or malignant 
form, and is represented on the skin by small capillary hemorrhages. It 
is often rapidly fatal, and at times appears to be part of a general hemor- 
rhagic diathesis represented by epistaxis, hematuria, and hemorrhages 
from other localities. The temperature in these cases is not typical, as it 
does not remit in the prodromal stage, thus depriving us of an important 
means of diagnosis ; but a doubt as to the nature of the disease does not 
last long, as the other symptoms soon become prominent. The more 
prolonged the course of this form the better the prognosis, for if fatal it 
is usually quickly so. It may be complicated by a malignant broncho- 
pneumonia. 

The efflorescence, besides differing in its form, may vary to a great 
degree in its intensity. Thus, we may have every grade of papule or 
macule, from the smallest to the largest, and varying from a dark purplish 
to a light pink color. In like manner, although the arrangement of the 
efflorescence, especially on the chest, is somewhat crescentic, yet during 
epidemics of undoubted measles this crescentic shape is often absent. 
Instead of the efflorescence first appearing on the face and then extending 
to the thorax and extremities, we may find in undoubted measles that it 
begins first on the chest or some other part of the body ; or the efflores- 
cence may appear on the face and thorax simultaneously. We may also 
find that in certain cases the efflorescence appears first on the abdomen, 
or on the thighs, and yet the presence of other typical and undoubted 
cases of measles in the vicinity or in the same house assures us that we 



SPECIFIC INFECTIOUS DISEASES. 589 

are dealing with the same disease. The efflorescence instead of lasting for 
a number of days may be evanescent and may subside within twenty- 
four hours. The entire absence of efflorescence is said to occur in some 
cases, but must be considered very rare, and its possibility has been 
doubted. 

The desquamation of measles is of so light a grade that it is not sur- 
prising that in some cases no desquamation whatever is detected. Cases 
in which desquamation occurs without efflorescence are highly improb- 
able, although such have been reported. 

During certain epidemics of undoubted measles cases have not infre- 
quently been noted in which the post-aural and cervical glands were 
enlarged. 

There is a form of measles, called the recurrent, which is closely allied 
to relapsing fever. The main characteristic of this form is the high fever. 
The temperature will sometimes be raised for five or six days, will then 
become normal for seven or eight days, and will then rise again with a 
recurrence of the symptoms. This is a very unusual form, and one which 
needs merely to be mentioned here. It is accompanied by the general 
symptoms connected with the nose, eye, and bronchi which are met with 
in the typical form of measles. 

Relapses have been reported to occur in measles, but they must be 
very uncommon. I have never met with such cases. 

In reviewing the pictures which have been given of these variations, 
it must be evident that, although in the large proportion of cases measles 
runs so typical a course that the diagnosis is very easily made, yet such 
great variations in type are always so liable to occur that we should be ex- 
tremely careful not to make a diagnosis of certain other diseases, such as 
rubella, except under unusual circumstances. This is important, because 
we know that during epidemics of well-marked measles all these great 
variations as to incubation, prodrome, efflorescence, desquamation, and 
the entire course not infrequently arise. 

A case which occurred in my wards at the Boston City Hospital during 
an epidemic of measles which took place in that institution illustrates how 
greatly the symptoms and appearance of the disease may vary. The 
cases occurring in the hospital were almost without exception of the 
typical form, in which no mistake could be made as to the diagnosis of 
measles. 



A girl who was in the hospital, and who was exposed to infection from the 
patients with measles, after feeling perfectly well on the previous day, was found in the 
morning to have slight coryza, cough, and a papular efflorescence not confluent even 
on the face, small in size, light pink in color, and not crescentic. While the efflores- 
cence lasted the appetite was somewhat lessened, and the temperature was about 37.5° 
C. (99.5° F.). At the end of twenty-four hours the efflorescence had almost faded, 
and in a few days the general symptoms passed away, the patient's appetite had re- 
turned, the temperature had become normal, and she seemed perfectly well. 



590 



PEDIATRICS. 



If this case had been met with as a sporadic one, it would have been impossible 
to make the diagnosis of measles, and from its mild nature it would have been sup- 
posed to be some slight form of disease, such as rubella. 

I have met with cases of this type quite frequently, both during epi- 
demics and sporadically ; their cause is always obscure, and in them the 
diagnosis between measles, rubella, and papular erythema is often impos- 
sible. 

The following chart represents the temperature during the stage of 
invasion and efflorescence in a typical case of measles, and also the ac- 
companying mild congestion of the membranse tympanorum which is so 
common in measles, and which in this case appeared on the eighth day 
and closely followed the efflorescence on the face : 



CHART 24. 





J)ai/s 


of Disease 




F 


i 


2 


3 


4 


5 


6 


7 


8 


9 


10 


II 


12 


13 


14 


c 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORMl 
TEMP 
98° 

97° 

96° 

[ 95° 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


Si E 


M E 


M E 


M E 


M E 


415° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 

36 6° 

36.1° 
35.5° 
35.0° 
































I 


ffl 


'or 


est 


w 


ice 




















/ 




























f 


\ 






















0. 






V 






















7 


S 




V 


■v 






Co 


V^L 


9S/ 


tor 


? 






I 














y 


G> 


c e< 


2/lf 








f 








A 






f 


/ 












TO 








/ 




~l 




--- 




S 


| 



















































































































Measles with congestion of membranae tympanorum during stage of efflorescence. 

Complications and Sequels. — There are quite a number of complica- 
tions and sequelae which may occur in the course of measles. The most 
common of the serious ones are pertussis, pneumonia, and tuberculosis. 

Pertussis. — Pertussis seems to have an intimate connection with mea- 
sles, and its occurrence in the course of measles renders the prognosis 
more grave. 

Broncho-Pneumonia.- — The bronchitis which is so common an accom- 
paniment of measles sometimes appears in a more severe form, attacking 
the smaller bronchi as well as those of medium size, and may result in a 
broncho-pneumonia, which is much more common as a complication of 
measles than is lobar pneumonia. The broncho-pneumonia does not, 
however, appear to be more severe when it arises as a complication of 



SPECIFIC INFECTIOUS DISEASES. 591 

measles than when it occurs separately from that disease. Broncho- 
pneumonia as a complication of measles may occur very early in the 
course of the disease, even during the stage of invasion ; but it occurs 
most commonly towards the end of the second week. 

When, therefore, after the efflorescence has faded and the fever has 
subsided, the temperature again rises without evidence of local irritation in 
the throat, ear, or glands, we should suspect that a broncho-pneumonia 
is developing. The additional symptoms of quickened respiration and 
the movement of the alae nasi will render still more probable the suppo- 
sition that this complication is arising, even though nothing abnormal is 
detected in the lung itself. The absence of abnormal physical signs in 
the lung in the early stage of broncho-pneumonia is quite common. In 
infants the temperature of tubercular broncho-pneumonia does not seem 
to differ very much from that of ordinary non-tubercular broncho-pneu- 
monia. The congestion of the larger bronchi, which appears to be almost 
a part of measles, may become subacute and chronic, instead of, as is 
usually the case, passing off soon after the maximum of the temperature 
and efflorescence. 

Pleuritis may occur in the course of measles, but is not so common 
as pneumonia. 

Otitis Media. — When an otitis occurs as a complication of measles it 
is characterized by the conditions described on page 582. In treating this 
complication the nose and naso-pharynx should be kept as clear as pos- 
sible. The ear should be. as in the cases described in speaking of the 
treatment of the ear in scarlet fever, gently inflated, by means of the 
Politzer bag, and the atropine solution (Prescription 80, page 570), to- 
gether with dry warmth, should be used. 

The following case illustrates this aural complication occurring in 
measles : 

A girl, one year and seven months old, previously well, was attacked on March 6 
with coryza, cough, lachrymation, a heightened temperature, quickened respirations, 
and a rapid pulse. An efflorescence of measles appeared on the face on the following 
day, and the child felt sick, coughed continuously, and had a hoarse voice. The respi- 
rations varied from 36 to 40, the pulse from 170 to 180. The skin was hot and dry, 
and the throat was somewhat reddened. In the afternoon the temperature in the axilla 
was found to have risen to 40.2° C. (104.8° F.). She vomited and had a convulsion. 
The nervous symptoms passed off in a few hours, free perspiration followed, and the 
cough became somewhat looser. At 8 o'clock in the evening the temperature was 
40.1° C. (104.4° F.), the respirations were quickened, and the pulse was rapid. 
Nothing abnormal was found on physical examination of the chest. During the night 
she was somewhat delirious, and very wakeful and fretful. The temperature remained 
at about 40° C. (104° F.), the respirations were rapid, and the alae nasi moved so per- 
ceptibly that it seemed as though a pneumonia must be developing. Frequent and 
careful examinations of the lungs, however, failed to show anything abnormal. She 
continued to be very restless during the night and the efflorescence appeared thickly 
on the abdomen and legs, but very slightly on the chest. She complained of pain in 
the chest from the continuous cough, but did not show any symptoms of pain or dis- 



592 PEDIATRICS. 

comfort elsewhere. Towards morning it was found that an otitis of the left ear had 
developed, which in a few hours caused perforation of the membrana tympani. As 
soon as there was a free flow of pus from the ear the temperature fell to 38.8° C. 
(101° F.), the respirations became quiet and normal, the alas nasi ceased to move, 
and the child fell into a quiet sleep. On the next day the efflorescence was pro- 
nounced all over the body, face, and extremities. From this time the measles ran its 
usual course, and was followed by desquamation and complete recovery. 

The aural complication, however, proved to be very intractable/, and although it 
was carefully treated, lasted for many months. The perforation of the membrana tym- 
pani did not completely heal for over a year, but the case finally resulted in complete 
recovery without any disturbance of hearing. 

Bye. — In addition to the conjunctivitis which is a common accompani- 
ment of measles, and which, as a rule, requires no treatment beyond the 
protection of the eyes from light, the inflammatory process may extend 
to the deeper tissues of the eye and cause other grave lesions, such as 
blenorrhagic conjunctivitis, keratitis, and iritis. These complications should 
be treated at once by a skilled oculist. 

Tobeitz has called attention to the deleterious influence of measles in 
rendering more active any subacute or chronic affections of the eye which 
may have existed previous to the disease. 

Thyroid Gland. — In a number of cases an acute swelling of the thy- 
roid gland may take place during the course of measles. This swelling 
of the thyroid gland may even cause marked dyspnoea by pressure, but it 
usually disappears in two or three days. In some cases, however, a for- 
mation of pus has taken place, followed by destruction of a part of the 
gland. In intractable cases of this kind it has been found that the exter- 
nal application of iodine is useful. 

Lymph-Nodes. — Enlarged cervical lymph-nodes are not so common 
in measles as in scarlet fever, but they may occur, and may even prove 
serious from the occurrence of suppuration. 

Kidneys. — At times, at the height of the efflorescence, albumin may 
appear in the urine ; but this is frequently merely a transient congestion 
of the kidney, due to the high temperature, and corresponding to the same 
condition in the period of efflorescence in scarlet fever. Nephritis may 
complicate measles, as it does scarlet fever, but it is comparatively rare. 

Tuberculosis. — The most common sequela of measles is tuberculosis. 
This may occur either as a general miliary tuberculosis or as a tubercular 
disease of any of the organs or the joints. Tubercular disease of the joints 
seems to show a special predisposition to follow attacks of measles. It is 
noticeable that when a patient with a tubercular joint has an attack of 
measles the process in the joint is apt to become temporarily more active, 
and the prognosis is consequently more grave. The organ which in 
measles is most commonly affected by tuberculosis is the lung, and the 
most common form of tuberculosis of the lung is a tubercular broncho- 
pneumonia. Tuberculosis of the lung may often occur as a sequela of 
measles when pneumonia has not been present. In infants the tempera- 



SPECIFIC INFECTIOUS DISEASES. 593 

rare of tuberculosis does not seem to differ very much from that of 
an ordinary broncho-pneumonia. In regard to the relation which exists 
between measles and tuberculosis, we should appreciate the danger, which 
seems to be a serious one, that the micro-organism of measles will render 
active an old and quiescent tubercular nidus, whether it be in the bron- 
chial or the cervical glands or elsewhere. 

The following case illustrates the infection of a patient with measles 
by the tubercle bacillus. 

A girl, six years old, was always well until she had an attack of measles. Although 
there was no acute pulmonary affection following the attack of measles, she began to 
be affected with slight dyspnoea and a cough about one month after the measles had 
ended. A year later these symptoms increased, and she had swelling of the feet and 
complained of general malaise. She also lost considerably in weight and strength. 
On physical examination dulness was found at the apices of both lungs, and over the 
dull areas coarse and fine moist rales. Nothing abnormal was found in connection with 
the heart or kidneys. The temperature varied from 37.7° to 38.8° C. (100° to 102° F.), 
the respirations from 30 to 50, and the pulse from 120 to 130. An examination of the 
sputum showed the tubercle bacillus to be present. 

Paralysis. — Another sequela, although a rare one, is paralysis. Cases 
thus complicated have shown mostly a paraplegia, and, according to Osier, 
frequently can be classified as post-febrile polyneuritis, although it is pos- 
sible that some of them may be due to a rapidly ascending myelitis. 

Noma. — A very rare sequela of measles is the disease noma (cancrum 
oris). 

Among the rarer complications cf measles are empyema, endocarditis, 
pericarditis, and membranous laryngitis. Catarrhal laryngitis and tracheitis 
are not infrequent accompaniments of the acute stage of measles. (Edema 
of the glottis is rare, but has been known to occur. 

The irritation of the intestine, occurring commonly during the height 
of the efflorescence and temperature, sometimes becomes much more 
severe from the development of colitis as a complication. 



RUBELLA. 

Rotheln ; German Measles. — It is now almost universally believed 
that there is, in addition to variola, varicella, scarlet fever, and measles, 
a highly infectious acute disease accompanied by an efflorescence on the skin 
which is distinct from these other members of the group of exanthemata. 
While we must recognize the propriety of mentioning the existence of 
this disease when speaking of this class of affections, we must also ac- 
knowledge that it is the weight of opinion, and not of proof, which has 
characterized rubella as a disease sui generis. The cause, the sympto- 
matology, and the resulting diagnosis of rubella must be left for future 
investigation, until the special micro-organism which produces it and 
that which produces measles can be separated bacteriologically. The 

38 



594 PEDIATRICS. 

difficulty which arises in differentiating rubella from the other diseases 
of this class is chiefly in distinguishing it from measles. We cannot 
describe a typical case of rubella in such a way as to enable us to diag- 
nosticate the disease in a sporadic case. On the other hand, this can be 
done so readily with the other exanthemata that we can at once diagnos- 
ticate a sporadic case. 

Symptoms. — Rubella is described in many ways by observers in differ- 
ent localities, but is usually spoken of as essentially a highly infectious 
disease, with an incubation of two or three weeks, with slight or no pro- 
dromata, and with a slightly raised temperature, accompanied by mild 
catarrhal symptoms, and often by sore throat and swelling of the cervical 
and post-auricular glands. 

Efflorescence. — The efflorescence is commonly described as papular or 
macular in form, of light grade, often evanescent, and seldom showing any 
desquamation. Forchheimer has described what he designates as an ex- 
anthem appearing on the mucous membrane of the fauces at the same time 
that the efflorescence appears on the skin. This exanthem has the same 
characteristics as that on the skin, excepting so far as it is modified by 
the difference in locality. Forchheimer believes that this exanthem is 
characteristic of German measles, and states that it is very short-lived, 
fades away within the first twenty-four hours, and is localized upon the 
velum of the palate and on the uvula, but rarely invades the hard palate 
or any other part of the mouth. The efflorescence consists of macular, 
distinctly pink-red spots resembling the roseola of typhoid fever, arranged 
irregularly, not crescentically, about the size of large pin-heads, very little 
elevated above the level of the mucous membrane, and with very little 
infiltration. These spots come out in their largest circumference, do not 
increase in size, and during their involution sometimes leave yellowish- 
brown spots or streaks. Koplik's spots, considered by him to be charac- 
teristic of measles, are said never to be present in German measles, 
but have been found by Widowitch ten times in a series of one hundred 
and thirty-five cases of rubella. 

Complications or sequelae following rubella are said to be uncommon. 
If a careful study is made of the variations which occur commonly 
during epidemics of undoubted measles, it will be seen that this descrip- 
tion of rubella is one which may be applied to many mild cases of 
measles. As, however, epidemics arise in which these characteristically 
mild symptoms occur in many cases, and these cases may give rise to 
similar cases, it is probable that in the future a micro-organism distinctive 
of rubella will be found. 

Diagnosis. — Bearing in mind the facts which have been mentioned, we 
can merely say regarding rubella that its diagnosis can seldom be made in 
a sporadic case. 

Prognosis. — The prognosis is good. 

Treatment. — The treatment is that of a mild case of measles. 



SPECIFIC INFECTIOUS DISEASES. 595 

VARIOLA. 

Etiology. — Variola (small-pox) is one of the most virulent of the 
infectious diseases with which we have to deal, and is particularly fatal 
among infants and young children. The micro-organism which causes 
this disease has not yet been determined. It is characterized by severe 
constitutional symptoms, accompanied by a progressive efflorescence from 
macules and papules to vesicles and pustules, followed by the formation 
of crusts, these lesions having a tendency to result in cicatrices. Variola, 
in contradistinction to varicella, scarlet fever, and measles, is an ex- 
tremely rare disease among infants and young children who have been 
vaccinated. 

Although there are no characteristics of variola which are distinctive 
in children from those of the disease occurring in adults, it is important 
to recognize its chief features for the purpose of differential diagnosis. 
It is possible for the foetus to contract the disease in utero. This, how- 
ever, is rare, and it is well known that infants whose mothers are 
affected with variola can, even when born in small-pox hospitals, be pro- 
tected from the disease if vaccinated immediately. The contagium is 
supposed to exist in the secretions and excretions, and to emanate from 
the exhalations of the lungs and from the skin. It is in all probability 
transmitted principally by means of particles of the crusts. It has a 
wonderful tenacity for clothing or any like means of conveyance. It 
has been proved that the contagium is active before the efflorescence 
occurs, though not so much so as later. It has also been fairly well 
proved that its activity ceases when all the crusts have fallen off and 
when the entire skin has become smooth. The most virulent form of 
the disease can be contracted from a mild form, such as varioloid. 

Pathology. — The pathological conditions found in variola are chiefly 
those of the skin and the mucous membranes. The lesion begins as a 
round, somewhat raised macule, which develops into a hard papule, and 
later a small vesicle arises on its summit. This vesicle enlarges very 
rapidly and changes to a tensely filled pustule with a central depression. 
The size of this pustule corresponds to that of the original macule. 
Microscopically the macule consists of a circumscribed spot of hyperemia 
in the capillary layer of the skin. The papule is formed, according to 
Weigert, by a sharply defined necrobiotic degeneration of the under 
layers of the rete mucosum, by which process the nuclei of the epithelial 
cells are destroyed. By the transudation of fluid into these areas the 
cells are pushed apart and the epithelial layer is lifted up as a whole, 
covering the area affected, and forms a vesicle, the inner part of which is 
composed of a mesh-work filled with lymph. In the vicinity of the ne- 
crobiotic focus an inflammation is set up, causing an increased growth of 
the cells of the rete which surround and wall in the focus on all sides. 
The developed pustule extends through the whole thickness of the cutis 



596 PEDIATRICS. 

to the subcutaneous tissue. A net-work inside the pustule, which is most 
tense in the central part, connects the roof and floor of the pustule, 
and, in conjunction with the above-mentioned growth of the cells of the 
rete around the focus, causes the central depression. If the vesicle is 
pricked, only a part of the lymph flows out of the mesh-work within. 
The lymph is clear, and contains some white and red blood-corpuscles, 
streptococci and staphylocci, fibrin-flocculi, and molecular granules. The 
contents of the pustule are purulent, and those in the hemorrhagic form 
contain blood. Clumps of bacteria with analogous localized degeneration 
and its associated changes are found in the neighborhood of the pustules, 
also in the parenchyma of the internal organs and lymph-glands, as well 
as in the skin. When the variola has reached its height the central de- 
pression in the pustule disappears, because the increased tension in the 
contents tears away the mesh-work. The vesiculation begins in the 
upper central part and spreads downward towards the periphery. The 
pustule then collapses and changes to a crust, which after a certain 
number of days falls off, leaving a more or less deep scar covered with 
young epithelium. If the suppuration extends into this layer, scarring 
invariably results ; it does not necessarily follow if the suppuration is 
confined to the upper layer. A distinct difference in the anatomy of a 
pustule of variola vera and one of varioloid does not exist. 

On the mucous membranes of the mouth, nose, conjunctivae, bronchi, 
oesophagus, rectum, sometimes the vagina, and also on the tonsils and 
the tongue, the same pustular efflorescence may be found, and is either 
superficial or extends more deeply. At times also a pseudo-membrane is 
found on the ulcers. 

In the intestines swelling of Peyer's follicles is not uncommon. In 
the larynx the efflorescence may be associated with a fibrin exudate, and 
sometimes with oedema sufficient to cause death. Occasionally the inflam- 
mation extends deeper and involves the cartilages. In the trachea and 
bronchi there may be ulcerative erosions, but the characteristic lesions 
seen on the skin do not occur. There are no special lesions of the lungs, 
but congestion or broncho-pneumonia is very common. 

Conjunctivitis, keratitis, and inflammation of other parts of the eye 
may occur in the course of the disease or afterwards. 

Acute otitis media, with or without suppuration, is of common occur- 
rence. 

The pathological changes in the other organs consist of enlargement of 
the spleen and fatty degeneration of the liver, kidneys, and heart. Meta- 
static processes in the various organs and in the joints sometimes occur. . In 
the hemorrhagic form hemorrhages in the various cavities, in the different 
organs, and, according to Golgi, in the medullary cavities of the bones, may 
occur, also in the serous and mucous surfaces and in the muscles. The 
blood shows an active leucocytosis during the pustulous stage, and the red 
blood-corpuscles tend to form in clumps instead of rouleaux. 



SPECIFIC INFECTIOUS DISEASES. 597 

Incubation. — The incubation of the disease varies from twelve to 
fourteen days, the latter being the most frequent period. 

Symptoms. — According as the symptoms of variola are mild or severe 
the disease has been divided into a number of forms, designated as follows ; 
(1) discrete, (2) confluent, (3) hemorrhagic, and (4) modified. In all these 
forms the initial fever, convulsions, and general symptoms may be severe, 
and do not necessarily indicate which type of the disease is about to follow. 

(1) Discrete Form. — The mildest and most typical form of the dis- 
ease is that which is called discrete. 

Prodromata. — In this form, the invasion, although sometimes less 
severe than in the confluent and hemorrhagic forms, is in infants and young 
children almost always of a grave type. In infancy and early childhood 
the disease commonly begins with convulsions. There may be vomiting, 
great restlessness, rapid pulse, high temperature, and in a number of cases 
the children quickly succumb to the disease from the virulence of the 
toxaemia. If they survive this early stage of the disease they usually 
present the same sequence of symptoms as in cases occurring in later 
life, but may eventually die from the exhaustion which often rises from a 
prolonged suppurative fever. In the prodromal stage the pulse is much 
accelerated and the temperature may be as high as 40°, 40.5°, or even 
41.1° C, (104°, 105°, or 106° F.). In this stage we at times, especially 
among children, meet with an evanescent erythematous efflorescence. 
According to Simon, this manifestation is distinct from that of scarlet 
fever. It has a peculiar distribution and generally a limited extent, usu- 
ally affecting the lower abdominal areas, the inner surface of the thighs, 
the sides of the thorax, and the axillae; sometimes, however, it involves 
the whole surface. This efflorescence is distinct from the typical lesions 
of variola which occur later. 

Efflorescence. — On the third or fourth day of the prodromal symptoms 
an efflorescence appears on the skin, and at this time the frequency of the 
pulse lessens, the temperature usually falls considerably, and the more 
severe symptoms improve, so that the patient appears much more com- 
fortable. The efflorescence is at first represented by small red macules 
or papules, which, as a rule, first appear on the forehead, or on the face 
and mucous membranes, and later on the trunk and limbs. The papules 
are rather scattered in their distribution, and have a feeling as of shot 
under the skin. The macules when present soon become papules. On 
the third day by means of a good light a small vesicle can be seen at the 
apex of the papule, and by the fifth or sixth day the vesicular stage is well 
established and the vesicle becomes distinctly umbilicated. This appear- 
ance on careful examination can also be seen in the lesions of the mucous 
membranes. At about the eighth day the vesicles become pustules, the 
tops soon flatten, and the umbilication disappears, leaving an areola of 
injection and the intervening skin in a swollen condition. 

Temperature. — The temperature at this time rises, from the suppuration 



598 PEDIATRICS. 

which is taking place in the pustules. This rise of temperature is called 
the secondary fever, or fever of suppuration. The temperature remains 
high for from twenty-four to forty-eight hours, and then gradually falls 
until by the twelfth or thirteenth day it usually becomes normal. The 
contents of the pustules dry up, and crusts are formed. On the palms 
and soles small, hard disks form, which may of themselves fall off in 
infants, but in children as old as ten years would remain for a long time 
unless removed with the point of a knife. 

Blood. — On examining the blood in cases of variola Arnheim found 
the haemoglobin diminished at the beginning of the disease. After the for- 
mation of pustules and during their exsiccation, he found an increase of 
the haemoglobin with diminution of the erythrocytes. When compli- 
cating suppuration occurred both the erythrocytes and the haemoglobin 
remained for a long time abnormally diminished. 

Pick in forty-two cases found no leucocytosis except in the stage of sup- 
puration or in some complication like pneumonia. This was the case even 
when the temperature was high, the disease severe, and the termination 
fatal. 

Desquamation. — By the fourteenth or fifteenth day the stage of desqua- 
mation is established. In some cases extensive scars are left on the skin 
where the crusts have fallen off. This is most apt to occur in severe 
cases. 

(2) Confluent Form. — In contradistinction to the mild or discrete 
form of variola is the more severe form, called confluent, on account of 
the tendency of the lesions to coalesce. In the confluent form of variola 
the efflorescence usually appears at the same time as in the discrete form. 
At about the fourth day the lesions become confluent, the skin becomes 
reddened and swollen, and the face may be much distorted by the severity 
of the lesions. In this form the initial temperature does not fall to the 
same degree as it does in the discrete form, and, according to Sydenham, 
diarrhoea is likely to occur, particularly in children. The pharynx and 
larynx are especially apt to be involved, and the cervical lymphatics to be 
enlarged. The crusts adhere longer in the stage of desquamation than 
they do in the same stage of the discrete form. 

(3) Hemorrhagic Form. — The third or hemorrhagic is the most viru- 
lent form of variola, and may occur in children as it does in adults, 
although not so frequently in the former as in the latter. Its symptoms 
in children are so severe that in almost every case it very quickly proves 
fatal. It is characterized by punctiform hemorrhages in the skin, appear- 
ing from the first to the fourth day of the prodromal stage, ecchymoses in 
the conjunctivae, and hemorrhages from the mucous membranes. Accord- 
ing to Osier, haematuria is the most common form of hemorrhage, haema- 
temesis the next. 

(4) Modified Form. — The fourth or modified form of variola occurs 
when the disease attacks individuals who have been successfully vacci- 



SPECIFIC INFECTIOUS DISEASES. 



599 



nated. This form is called varioloid, but would be better termed viodified 
small-pox. Modified small-pox is usually much milder in its symptoms 
than any of the other forms of variola, although the initial fever may be as 
high as in a severe case. The papules are fewer in number, the tempera- 
ture becomes normal sooner, and the child seems comfortable in a shorter 
period of time, since there is usually no secondary fever from suppura- 
tion. The nearer the attack comes to the time when the child was 
vaccinated, the less severe will be the symptoms. 

In any of these forms of variola the prodromal symptoms may be of a 
very severe nervous type, and this is especially characteristic of the disease 
as it occurs in children. For this reason variola may simulate other 
diseases in its prodromal stage, and may often cause death before the 
efflorescence has appeared. This is especially the case with the prodromal 
symptoms of the hemorrhagic form. 

The following chart represents the usual temperature curve of the 
initial fever and the suppurative fever in a typical case of variola. 















CHART 


25 
















_D<2l/S oFDzSGCtSG 




F 


I 


2 


3 


4 


5 


6 


1 


8 


9 


10 


ii 


12 


13 


14 


c 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORM'L 
TEMP, 

98° 
97° 
96° 
95° 


M E 


H E 


U E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 

36 6° 

36.1° 

35.5° 
35.0° 
































/ 


























4 


/ 


A 










/ 


• 












T 




V 










/ 




| 










T 












/ 


/ 




h 










T 










/ 


7 






i 








f 






/ 


V 


V 


















f 






V 




V 












I ■ 


A 




L~j 






















V 


V 


^- 

















































































































Fever of invasion. Fever of suppuration. Variola. 

Complications. — The most common complications of variola are those 
of the larynx and the lungs. When the larynx is affected, oedema of the 
glottis may suddenly arise and death take place from suffocation. When 
a lesion of the lung develops, it is usually in the form of a broncho- 
pneumonia. Lobar pneumonia rarely complicates the disease. 

In the throat the presence of the efflorescence occasions great irrita- 
tion, and the accompanying secretions cause nausea and at times dyspnoea, 
with a cough which in weak children is very exhausting. 

When acute inflammation of the middle ear has taken place the pain 
during the formation of the pus is very intense, but it subsides as soon as 



600 PEDIATRICS. 

the sac bursts or is incised. This complication, therefore, requires early 
and careful treatment. 

Although albumin is very frequently present in the course of the dis- 
ease, nephritis is rare. 

Diagnosis. — There is no other constitutional disease accompanied by 
an efflorescence on the skin which in a typical case would be likely to be 
mistaken for variola. The severe constitutional symptoms, the slowly 
developing and rather scattered macules and papules, with the shotty feel- 
ing of the latter, the umbilicated vesicles gradually becoming pustules, the 
extensive crust formation, and the initial and suppurative fever, all render 
the diagnosis in most cases quite plain. 

Extreme cases of varicella have been mistaken for variola. The dif- 
ferential diagnosis between the two diseases is given in the table on 
page 612. 

Variola differs materially in its prodromal symptoms from measles, in 
which the pronounced catarrhal symptoms of the nose and eyes make 
the differentiation comparatively easy. Although the prodromal symp- 
toms of scarlet fever and of variola, such as the convulsions and vomiting, 
are often of equal severity and somewhat similar, yet the pronounced 
symptoms connected with the throat in scarlet fever, and the appearance 
of an erythematous efflorescence, instead of the scattered papules of 
variola, serve to differentiate clearly the two diseases. We must, how- 
ever, be careful not to mistake the evanescent efflorescence which occurs 
in the prodromal stage of variola for the erythema of scarlet fever. The 
distinction can usually be made by remembering that the efflorescence in 
variola has the peculiar distribution described under prodromata on page 
597, while the typical location of the efflorescence of scarlet fever is 
first on the neck and chest. 

In making the diagnosis of variola Ave must bear in mind the efflores- 
cence Avhich appears on the skin in the course of a general vaccinia. In 
vaccination the single lesion and the absence of severe constitutional 
symptoms make it hardly necessary to do more than refer to it in this 
connection. The differential diagnosis from general vaccinia is not difficult, 
and yet general vaccinia is so rarely met with that when it appears it 
almost always creates a suspicion that we may be dealing with variola. As 
a rule, in vaccinia the general symptoms are not severe, the disease being 
represented almost entirely by a slight malaise and loss of appetite, in con- 
junction with the appearance on the third or fourth day of an efflorescence 
on the skin, represented by papules, vesicles, and pustules, few in number 
and irregularly distributed, some on the face and nose and a few on the 
body and extremities. As these manifestations almost invariably appear 
after vaccination, this fact is of great aid in the differential diagnosis from 
variola. The subsequent course of a case of vaccinia is so much milder 
and shorter than that of variola that in a few days the differential diagnosis 
can be made easily. 



SPECIFIC INFECTIOUS DISEASES. 601 

Prognosis. — The prognosis of variola depends upon whether the child 
has been vaccinated, and also upon whether children who have been vac- 
cinated when infants have been revaccinated. In the unvaccinated the 
prognosis is always bad, and is proportionately grave the younger the 
child. In the vaccinated the prognosis is good, and is proportionately 
favorable to the shortness of the interval between the invasion of the 
variola and the time of the previous vaccination. 

Treatment. — There is no specific treatment for variola, but it is of the 
utmost importance that the best hygienic care should be employed. The 
air of the room should be perfectly fresh. The crusts should be kept 
softened with a mixture of glycerin, oil, and carbolic acid, and the odor 
arising from them should be modified by the application of a dilute 
solution of carbolic acid. 

In the initial stage of the disease stimulants should be freely given if 
the symptoms are severe, and the high temperature should be controlled 
by sponging with water at a temperature corresponding to the power of 
the child's reaction. 

The greatest care should be taken during the stage of convalescence, 
and when the child is considered well the most rigid measures for pre- 
venting the spread of the contagium should be enforced. The clothing 
and everything connected with the child and its attendants, and the room 
in which they have been kept during the sickness of the child, should be 
thoroughly disinfected, the same precautions being taken to prevent the 
spread of variola as in scarlet fever. The immediate transference of a 
patient from its room to a small-pox hospital is in most communities con- 
sidered the wisest method of dealing with the disease, and is usually 
enforced by law. 

VACCINIA. 

Vaccinia (cow-pox) is a specific eruptive disease occurring in cattle, 
especially in cows. The disease in human beings may be either a local 
affection, spreading from a point of inoculation, such as from vaccination, 
or may be a general manifestation arising from the entrance of poisonous 
matter into the blood. It is supposed that vaccinia may occur either by 
the introduction of the vaccine lymph into the blood or by auto-inocu- 
lation, and that the latter is probably the more common way. The 
disease is characterized by the appearance of papules, vesicles, and 
pustules of different sizes in different parts of the body and limbs, as wejl 
as on the face, and running a definite course. It may be said to be a 
rather rare disease. When its lesions follow vaccination they appear at 
about the fifth day after the inoculation. At the end of four days, however, 
minute vesicles can be seen with the magnify ing-glass. 

Vaccination. — By vaccination is commonly meant the inoculation 
with the virus of vaccinia as a preventive of variola. During a period of 
fifteen years no death has occurred from variola in Boston of a child who 



602 PEDIATRICS. 

had been -vaccinated before it was five years old. During the same 
period the percentage of deaths among the unvaccinated at the Boston 
Small-Pox Hospital was seventy-five per cent., while that of the vacci- 
nated was three per cent. For the past seventeen years no person who 
has been successfully vaccinated within five years has died of variola, and 
those who have been attacked by variola have had the disease in a very 
mild form. In order to show the relative frequency of deaths occurring 
in the vaccinated and in the unvaccinated I have arranged the following 
table, based on a report by Dr. Barry of an epidemic of variola at Shef- 
field, England, during 1887 and 1888. The table shows the percentage 
of those who, living in houses invaded by variola, were attacked by the 
disease, and also how many of these died. It also gives the percentages 
for all ages, and for those under ten years and over ten years. 

TABLE 66. 

Individuals living in Houses invaded by Variola. 

1. 2. 3. 

All ages. Over ten years. Under ten years. 
Per Cent. Per Cent. Per Cent. 

Vaccinated /Attacked 23.0 28.1 7.8 

I Died 1,1 1.4 0.1 

TT . , , f Attacked 75.0 68.0 89.9 

Unvaccinated. . . . < ^. _, 

I Died 37.2 37.1 38.1 

The low percentage of children as shown in column 3 is very striking 
in comparison with column 2, which represents older individuals, and 
enunciates the importance of revaccination. It also impresses upon us 
the significance of the difference in the number of deaths between the 
vaccinated and the unvaccinated. When large numbers of cases of 
variola have been reported figures show that among the vaccinated nine- 
teen out of twenty recover, while of the unvaccinated fifty individuals 
out of one hundred die. It is therefore evident that vaccination is highly 
protective against variola, and physicians should insist on the vaccination 
of every individual in the community. One vaccination, however, does 
not protect for a lifetime. On the contrary, revaccination is just as im- 
portant as the primary operation. One attack of variola does not always 
protect an individual from a second invasion, and more should not be 
expected from vaccination. 

Revaccination should be performed at intervals of eight or ten years, 
and in a shorter time when cases of variola appear in a community. The 
danger of serious results arising from vaccination is extremely small. 

The time at which vaccination should be done is of considerable im- 
portance. The infant should be vaccinated early, before it begins to be 
exposed to the danger of contagion from sources outside of its home. 
We must, however, remember how low is its vitality at birth, and how 
readily this vitality is affected by what would be considered trifling con- 
ditions for the older child or for the adult. A time should be chosen 
when the infant is not subject to the other disturbing conditions which 



SPECIFIC INFECTIOUS DISEASES. 603 

naturally arise in the first two years of life, such as weaning and the irri- 
tation of the dental periods. If it is found necessary to vaccinate the 
infant after the sixth or seventh month, or before the twentieth, it should 
be done in an interdental rather than in a dental period, and not at the 
time when its food is being changed, or when it is suffering from either 
slight catarrhal conditions or some definite disease. I prefer to vaccinate 
the infant when it is four or five months old. — that is. just before the 
period when the first tooth appears. At this age it has usually become 
accustomed to its food, its digestion is in equilibrium, and its vitality is 
much above what it Avas in the early weeks of its life. By the fifth 
month also it will usually have developed the outward symptoms of 
syphilis if it has inherited that disease from its parents. 

The vaccine virus can be introduced into any part of the body through 
the skin, and according to the fancy of the physician or parents. Girl 
infants can be vaccinated just below the knee on the outer side of the leg, 
so as to avoid having a scar on the arm. to which women usually object. 
I am accustomed to vaccinate boys on the outer side of the upper arm. 
Whether the vaccination is performed upon the leg or the arm, we should 
first inquire if the person who is to take care of the infant is right- 
handed or left-handed. If the nurse, for instance, is right-handed, she 
will naturally hold the infant on her left arm. and in this case, the infant's 
right arm being towards the nurse, it is better for the vaccination to be 
on the left arm. The process should be reversed when the nurse is 
left-handed, and in this case, for the same reason, it is better to vaccinate 
on the right arm or leg. The form of virus which I have been accus- 
tomed to use, and which I consider the best, is taken from cows rather 
than from human beings. It should be very carefully prepared by those 
avIio have made a scientific study of the subject, and, if possible, on farms 
which are under State supervision. 

It has been pretty well proved by careful observation of large num- 
bers of primary vaccinations that those who in later life contract variola 
have the disease in a less severe form when in their primary vaccinations 
they have been inoculated in three places at once rather than in two, and 
in two places at once rather than in one. The general constitutional 
disturbance also does not appear to be greater when the inoculation has 
been in two or three places rather than in one. The evidence therefore 
seems to be in favor of inoculating in two or three places in primary 
vaccinations. A very small surface is amply sufficient for the proper in- 
troduction of the virus. A pointed ivory quill charged with glycerinated 
lymph (such as is shown in Plate IX.) can be used directly for removing the 
epithelium, for exposing the smaller blood-vessels, and for introducing 
the virus. I prefer not to use any more instruments than possible, in 
order to avoid the possible introduction of some foreign substance which 
might interfere with the natural course of the vaccine virus and cause 
unnecessary inflammation. 



604 PEDIATRICS. 

The utmost precaution should be taken to insure against infection 
from other micro-organisms besides the vaccine virus. The part of the- 
skin chosen for the vaccination should be thoroughly washed with soap 
and water and with alcohol. The hands of the operator should be clean 
and aseptic. A series of short scratches should be made about one-half 
centimetre (about one-fourth inch) long, four or five in number, and in 
two sets, one crossing the other, until the epithelium is sufficiently re- 
moved to show that the blood-vessels are exposed, but not to a degree 
that bleeding should take place, for in the latter case the virus may be 
prevented from gaining an introduction to the general circulation. The 
point of the quill should then be dipped into water which has been freshly 
sterilized. The flat part of the quill which is charged with the virus is 
then thoroughly rubbed into the wound. The skin should be protected 
for four or five minutes from contact with anything and then sealed with 
aseptic cotton and collodion. After two days this cotton can be removed, 
and, unless the subsequent lesion is broken, this measure is an additional 
safeguard against infection from extraneous matter in the first few days. 

Plate IX. shows the different stages of a vaccination as they occurred 
in one case carefully observed by the artist and myself every day. 

On the fifth day, as shown in the plate, a round, clear vesicle was seen at one end 
of the vaccination scratch, while at the other end there happened to be left a little 
brown crust. 

On the eighth day an irregular-shaped lesion about ^ cm. (£ inch) long, and 1 cm.. 
(J inch) wide, somewhat depressed in the middle, and with a clear vesicular border, 
appeared. 

On the tenth day the lesion had increased in length to 2 cm. (-£ inch) long, and to 
a little over 1 cm. Q inch) wide, and there was an erythematous condition of the skin 
forming an areola with a diameter of about 2 cm. (-£ inch), in the middle of which 
was the lesion just described. This areola was of a light shade of red, and on its outer 
border were irregularly distributed little light red maculae. 

On the twelfth day very nearly the same appearances were present as on the tenth 
day, except that the areola was very much more intense in its red color, and had grown 
to the size of a circle 3 cm. (1£ inches) in diameter. Some of the little maculae had 
become vesicles. 

On the sixteenth day, in place of the vesicular lesion with its depressed centre, a. 
crust had formed with a narrow line of redness around it, and on the outer border of 
this areola the redness gradually became fainter and shaded off into the normal skin. 

On the nineteenth day the crust was smaller, the redness had disappeared, and 
where the areola was most pronounced there was a slight desquamation. 

A vaccination scar at one year and twenty-one years is also shown in the plate. 

Every case of vaccination does not present exactly the same appear- 
ances. The lesions may differ in shape and size, and one individual may 
be affected more intensely by the virus than another ; one may have 
accompanying severe constitutional symptoms and another have none. 
The chain of lymphatics may be affected as far as the axilla or the groin. 

As a rule, the following description represents pretty well the usual 
course of the disease. After the vaccination, the skin shows nothing new 



PLATE IX 



Vaccine Quill. 



Vaccination Scratch. 



At5 ,h Dev. 



At 8*Day. 





At lO'^Day 



AH2' h Day. 




# 



At l6'. h Day. 



At !9' h Da) 



Scarar I 



Scarar 21 years. 



SPECIFIC INFECTIOUS DISEASES. 605 

until the third, fourth, or even fifth day, when a small red point appears. 
This soon becomes a papule ; by the next day a vesicle is developed ; 
about the sixth day this vesicle usually becomes umbilicated, and is sur- 
rounded by a faint red zone. By the eighth day the vesicle is fully de- 
veloped, and by the ninth day the reel zone increases rapidly and the 
vesicle soon becomes a pustule. By the eleventh or twelfth day a crust 
is formed, and this crust falls off from about the fourteenth to the twenty- 
first day, in some cases an ulcer being left which heals by another crust 
being formed, in others the skin remaining intact. From the eighth to the 
twelfth day there . may be a slight amount of fever and coated tongue, 
with some loss of appetite, and the glands of the axilla or groin may be- 
come enlarged and tender. The scar, although perhaps not typical, can 
usually be recognized by its small depressions (pits) and its location. 

In some cases, instead of the healing of the scratch in a few days, or 
the formation of the vesicle of a successful vaccination, irregular excres- 
cences of a fungus-like character may appear. These in all probability 
have no connection with the true vaccine virus, and are not protective. 
In addition to the rather rare cases of vaccinia, various efflorescences at 
limes appear on the skin, not only in the neighborhood of the vaccination 
lesion, but also in other parts of the body. They may be present on the 
fourth or fifth day, or even later, in the second week, and are probably 
caused by some reflex connection with the vaccination lesion. They vary 
considerably in form, but are usually represented by a multiple or papu- 
lar erythema or an urticaria. It should be remembered, when an un- 
vaccinated child has been exposed to variola, that if it is vaccinated 
within forty-eight hours it will probably be protected, and if within five 
or six days the variola poison will be so modified as to produce only a 
mild form of the disease. 

VARICELLA. 

Varicella (chicken-pox) is the mildest in its symptoms and the most 
favorable in its prognosis of the whole group of exanthemata. It is 
highly infectious, and is characterized, in distinction from the other exan- 
themata, by its long stage of incubation, the shortness or absence of any 
prodromal stage, its vesicular efflorescence, and the absence of sequelae. 

Etiology. — Varicella has been known as an independent disease for the 
last two centuries. At one time it was not clearly differentiated from 
measles and scarlet fever, and in some parts of the world it is supposed 
to be closely allied to variola. This opinion, however, is not generally 
substantiated, and we can accept varicella as a distinct disease. It can 
occur at any age, but the most common time for its appearance is in the 
middle and latter part of the first year. It continues to be a common 
disease all through the early and middle years of childhood. The suscep- 
tibility to the contagium of varicella lessens after ten years of age, and 
almost disappears at puberty. It is sometimes sporadic and sometimes 



606 PEDIATRICS. 

epidemic. It occurs with equal frequencv at all periods of the year. 
The vehicle of contagium is not known, but it probably enters the system 
by the lungs. The specific organism which produces varicella has not yet 
been determined. 

Pathology. — Deaths from varicella are so extremely rare that our 
knowledge of the pathology of the disease is necessarily limited. It is 
evident, however, that the efflorescence of vesicles, which represents the 
principal morbid lesion of the disease, is of a somewhat different type 
from that which occurs in variola. The vesicle is much nearer the sur- 
face than in the latter disease, being formed mostly by the upper layers 
of the epithelium. The vesicle itself is seldom multilocular, a condition 
which is frequently present in variola. The contents of the vesicles are 
usually a clear serum, the progression to a pustule being rare in compari- 
son with the lesion of variola. The lesion so rarely involves the deeper 
layers of the skin, and the process is usually so very mild, that it is seldom 
that sufficient destruction of the tissue takes place to produce a scar. 

The lesions may appear on the mucous membranes as well as on the 
skin. At times the lesions assume a much more serious form and may 
become gangrenous. In gangrenous varicella, according to Eustace Smith, 
the vesicles, instead of drying up in the ordinary way, become black and 
larger, so that a number of rounded black crusts are scattered over the 
surface of the body. If a crust be removed, it is found to cover an ulcer 
more or less deep. Around it the skin is of a dusky red color. All the 
vesicles do not become gangrenous, so that we find crusts of the ordinary 
appearance mixing with the blackened crusts. The gangrenous process 
often penetrates deeply through the skin to the muscles. The lesions at 
times are so extensive as to form ulcers which may invade and destroy 
large areas of tissue. 

Incubation. — The stage of incubation is variable, but lasts from eight 
or ten days to three weeks, the usual time being about seventeen or eigh- 
teen days. 

Symptoms. — Prodromata. — There are rarely any prodromata in vari- 
cella, beyond a slight malaise for a few hours. At times, however, espe- 
cially in young infants, the onset of the disease may be severe : it may be 
characterized by vomiting, and, when the temperature is high, even by 
convulsions. In rare cases the prodromal stage is of considerable length 
and the prodromata resemble somewhat those of the other exanthemata. 

Efflorescence. — The disease usually shows itself in the form of an 
efflorescence, the characteristic and most common lesion of which is a 
vesicle. The lesion, however, is in the beginning a macule, which quickly 
becomes a papule, and the papule so rapidly develops into a vesicle that 
it is in the vesicular stage that we usually first notice the efflorescence. 
These macules and papules are so superficial that they are soft to the 
touch and do not give the shotty feeling which is so common in these 
lesions when they occur in variola. The vesicle of varicella, as a rule, is 



SPECIFIC INFECTIOUS DISEASES. 



607 



not umbilicated, and its contents but rarely become pustular. It may 
be surrounded by a light red areola, but this is not present in all the 
lesions. The usual course of progression in the lesions is that the vesicle 
flattens, its contents are dispersed on the skin or absorbed, and a small 
crust is formed, which finally falls off, leaving the skin smooth and with- 
out a scar. Occasionally a scar results from some individual lesion in 
which the inflammatory process has involved the deeper layers of the 
skin. The efflorescence is irregular and general in its distribution, the 
lesions appearing on the face and head, in my experience especially behind 
the ears, on the body, usually first on the back, and finally on the extremi- 
ties. It comes out in successive crops, so that very different lesions may 
be found on the skin at once, representing the early and late manifesta- 











CHAKT 


26 












Daz/s of Disease 




F 

107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORM'L 
TEMP. 

98° 
97° 
96° 
95° 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


c 

41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36 6° 

36.1° 

35.5° 

35.0* 


M E 


M E 


M E 


a e 


tf E 


M E 


A E 


a e 


M E 


M E 




















































































1 


















_J 


f\ 


/ 
















7 


/ 


l\ 
















t 


V 


\ 


V 


V , 












L7- 








V 


V 


S 




































































i 

























Varicella simplex. 



tions of the efflorescence. It, however, may first appear in the throat, 
but is not so often seen in this location as is the efflorescence of scarlet fever 
or measles. It is possible that the efflorescence always appears first in 
the throat, but that in many cases it is not seen early enough to be recog- 
nized, as the manifestations are very evanescent. 

This efflorescence of varicella is almost the only one which is charac- 
teristic of a specific disease. By this I mean that while a vesicle does not 
necessarily allow us to diagnosticate any disease of the skin, yet when 
these vesicles with their areolae, in combination with constitutional symp- 
toms, appear in groups in different parts of the body, there is no other 
disease with which we should be likely to confound it, with the exception 
of variola, vaccinia, and possibly herpes zoster. 

The temperature in varicella is in most cases not high, and is very 



608 PEDIATRICS. 

irregular. It usually rises when a crop of lesions of any considerable 
number develops, and falls again at the outbreak. 

Chart 26, on page 607, shows the temperature in a typical case of 
varicella simplex. 

Diagnosis. — The diagnosis of varicella is not difficult if we bear in 
mind the characteristics of the diseases which it is most apt to simulate. 

From Variola, — In differentiating it from variola we must consider the 
great difference in the rapidity of the development of the efflorescence in 
the two diseases. In variola it is essentially slow, in varicella it is char- 
acteristically quick. The papules of variola are hard to the touch, those 
of varicella are soft. The vesicle of variola, as a rule, is umbilicated and 
soon becomes a pustule ; these characteristics are absent in varicella. 
The whole course of variola occupies a period of from two to three 
weeks ; the course of varicella is much shorter, and is often limited to 
one week. Finally, the severe constitutional symptoms and the long 
prodromal stage in variola differ essentially from the lack of prodromata 
and the mild constitutional symptoms in varicella. 

From Vaccinia. — In vaccinia the slow progression of the lesions from 
papules to pustules, and the rather limited areas affected, serve to dis- 
tinguish it from the successive crops of vesicles, with their rapid develop- 
ment and extensive areas, which are met with in varicella. 

From Herpes Zoster. — The differential diagnosis of varicella from her- 
pes zoster is not difficult, if we consider that the vesicular efflorescence in 
herpes zoster follows the course of some set of nerves, while that of vari- 
cella is perfectly irregular and is in no way connected with the distribu- 
tion of the nerves. 

The course of varicella is rapid. It is characterized by a sudden onset 
of constitutional symptoms, with the almost immediate appearance of the 
efflorescence. The efflorescence runs a rapid course, appearing quickly 
on different parts of the skin, and disappearing almost as quickly as it 
appears. The disease lasts about a week or ten clays, and, as a rule, has 
no serious sequelae. It is rarely complicated by any other disease. 

Complications. — During the course of certain epidemics, however, it 
has been noticed that the kidney is affected. This complication usually 
occurs after the efflorescence has almost disappeared, and in the second 
week from the time of the beginning of the attack. In these cases albu- 
minuria is present, and in all probability is caused by some form of 
nephritis, although nothing definite is known about this class of cases. 

Gangrenous Varicella. — A complication which at times arises in vari- 
cella is what is called the gangrenous form of varicella. Although it is 
most common in ill-nourished children, yet it does not necessarily attack 
this class of cases, and it seems to have some connection with the gan- 
grenous processes which certain individuals show a tendency to develop. 

The following table gives the chief points of difference between varicella 
and variola : 



SPECIFIC INFECTIOUS DISEASES. 609 

TABLE 67. 
Varicella. Variola. 

Incubation Two to three weeks. One to two weeks. 

Prodromata .None or slight. Three to four days in length. 

Active. Severe. 

Efflorescence Rapidly becomes vesicular. Not A slow progressive development 

umbilicated. Unilocular. Ir- from a macule to a papule, from 
regular. Lesions numerous. a papule to an umbilicated vesi- 
Universally distributed in sue- cle, then to a pustule. Multi- 
cessive crops. Vesicles differ locular. Regular. Lesions not 
greatly in size. On pricking, numerous. Defined in its locali- 
collapses entirely. zation. Lesions, as a rule, of 

uniform size. On pricking, col- 
lapses partially. 

Desquamation Slight crust formation. Pronounced crust formation. 

Duration Short, one week to ten days. Long, three to four weeks. 

Type Mild. Severe. 

Temperature Irregular, not high. Rises suddenly. Remains high 

until papules are developed, 
when it falls considerably. 
Rises again during the develop- 
ment of the pustules. 

Prognosis. — The prognosis of varicella is usually, unless the above- 
mentioned complications arise, extremely favorable. Cases occur in which 
the prognosis is rendered unfavorable by lack of proper care during the 
convalescence, resulting in broncho-pneumonia and other diseases. In 
some cases the prognosis is rendered unfavorable by the anaemia which 
is apt to follow an attack of varicella, and is at times pronounced. 

Treatment. — The treatment of varicella is simply symptomatic. The 
child should stay in the house, and its room should be kept at an even 
temperature. The diet should be milk. The child should be carefully 
watched to prevent it from scratching, as lesions deep enough to produce 
scars may often be obviated in this way. This treatment should be con- 
tinued until all the constitutional symptoms have passed away and the 
efflorescence has disappeared. Complete isolation should, if possible, be 
enforced, as, although the disease is usually insignificant, Ave can never in 
the beginning determine whether or not a rare and severe case is about 
to develop. 

These rules for treatment are precautionary, and are based on the 
supposition that a child who has had a constitutional disease of this 
nature must be more sensitive to exposure of various kinds. As it is 
possible in some cases for the kidney to be affected in the later stages of 
the disease, just as it is in scarlet fever, it is well to guard against this 
complication by the protection of the skin from changes of temperature 
and by the use of milk as a diet. In a considerable number of cases, 
especially in young children, an anaemia of greater or less degree results 
from the disturbance of nutrition which so often accompanies the disease. 
In these cases the administration of saccharated carbonate of iron or of 
tartrate of iron ana potash is indicated. 

39 



610 



PEDIATRICS. 



The following case represents an ordinary attack of varicella. A boy- 
was brought to the hospital to be treated for a supposed cold. On ex- 
amination nothing abnormal was found except the lesions shown in the 
throat in Plate X. 

The tongue was very slightly coated. The tonsils were not enlarged. The mucous 
membrane of the hard and of the soft palate and of the pharynx was slightly hyper- 
aemic. On the upper and right side of the hard palate and very near where it joined 
the soft palate were two small vesicles surrounded by distinct red areolae. To the left 
and below these lesions were three minute macules, two of which had almost become 
papules. 

This case illustrates very well the importance of making a thorough examination 
of the throat in children, for unless the throat had been examined this child would 
have been supposed to have had a cold and would have been allowed to remain in the clinic 
and thus spread the contagium. 

The following case illustrates still further the efflorescence of varicella 
when at its height and on the second day. The efflorescence on the 
back is shown in Plate X. 

A girl was attacked with headache and malaise in the morning. In the afternoon 
an examination showed an efflorescence in the throat, but there was also a well-marked 




Varicella. Stage of efflorescence, third day. 

vesicular efflorescence on the back. This efflorescence soon began to come out in crops 
in different parts of the body, on the limbs, behind the ears, and on the scalp. There 
were also a few lesions on the face. On the back were a number of lesions, some of which 
were simply macules, and again a few of the macules had become papules. In most 



PLATE X, 




9 










Erysipelas. 



* 



Varicel la 



Syphilis 




SPECIFIC INFECTIOUS DISEASES. 



611 



cases, however, the lesions were distinctly vesicular, varying in their contents to such a 
degree that sometimes they had a pearly white appearance and again the yellowish 
color of a vesicle which had become somewhat pustular. In other places the vesicles 
had broken down and little crusts had formed in their centres, which were somewhat 
indented. On pricking one of these vesicles it collapsed and was emptied of its entire 
contents, showing that it was unilocular. The vesicle of variola when pricked in this 
way would in most cases be only partially emptied, showing that it was multilocular. 

The lesions of varicella are well represented in Fig. 128. 

This child was brought from the surgical ward, where it was being treated with 
plaster-of-Paris bandages for an injury to the arm. The efflorescence, chiefly vesicular 
in character, first appeared behind the ears. The whole of the child's back was 
thickly covered with the efflorescence. The lesions were also on the arms, legs, abdo- 
men, and front of the chest. They also appeared on the chin, lips, face, nose, fore- 
head, and scalp. 

The plaster bandage was removed, as a fixed bandage should never be used during 
the course of any of the eruptive diseases, owing to the probability that extensive 
ulcerations will develop under them. 

The following case and chart are illustrative of gangrenous varicella : 

A child, three years of age, was brought to the hospital with Pott's disease, and 
with a paraplegia arising from a transverse myelitis caused by the disease. Nothing 



















CHART 


21. 
























Dat/s of Disease 




F 












\ 1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


w 


12 


13 


14 


15 


c 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

MQRML 
TEMP 

98° 
97° 

96° 
95° 


H E 


H E 


M E 


M E 


M E 


M EJM E 


M E 


M E 


U E 


M E 


U E 


M E 


M E 


M e|m E 


M E 


H E 


B E 


M E 


M E 


41.6° 

41.1° 

40.5° 

40.0° 

39,4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36 6° 

36.1° 

35.5° 

35.0° 
























































| 










/v 


i 


fi 


?<2i 


'k- 


































1/ 


\ 


on 




































V 


30 


w 


Vf 




















/ 


1 




/I 


\ f 


/ 




























1 / 


/ 


V 


V 


7 


V 


V 
























/ 




!/ 


V 






























\l 




/ 


V 


\M 






























P 


J 


L 






































































P< 


m 














V 


2TI 


oe 


lie 




















d\ 


'se 


2 St 


J 








































































' 



Varicella gangrenosa. 

abnormal was found in connection with the lungs, heart, or kidneys. Until the child 
was attacked with varicella the temperature was usually normal, but sometimes rose 
to 37.7° C. (100° F.), and occasionally as high as 38.3° C. (101° F.). 

About one month before entering the hospital the child became restless, and his 
temperature rose somewhat. On the following day the symptoms became more 
marked, and the temperature was found in the evening to be 39.4° C. (103° F.) On 
this day an efflorescence of varicella appeared on his skin. During the third day of 



612 



PEDIATRICS. 



his sickness his face swelled, and in the evening his temperature was found to be 
41.1° C. (106° F.). The vesicular efflorescence was well developed on his trunk and 
face by this time. Somewhat later it became universal and assumed a purulent char- 
acter, especially about the face. During the fourth, fifth, and sixth days of the dis- 
ease his temperature varied in the evening from 39° C. (102.2° F.) to 39.4° C. (103° 
F.). On the seventh day of the disease all the symptoms increased in severity, 
and the temperature was found to be 41.1° C. (106° F.) On this day some of the 
vesicles on the face had become ulcers. Nothing abnormal was found in the lungs, 
and no albumin or casts in the urine. A psoas abscess developed during the progress 
of the varicella. The ulcers on the face extended to such a degree that the child lost 
the sight of one of its eyes. The child sank rapidly. The treatment, which was 
essentially with stimulants, failed to keep up its strength, and the local treatment in 
connection with the eye proved entirely unsuccessful. 

The child continued to grow weaker, and died on the thirtieth day from the time 
when the first symptoms of the varicella were noticed. No autopsy was obtained. 



DIFFERENTIAL DIAGNOSIS OF THE EXANTHEMATA. 

The characteristics of this group of exanthemata are as follows. In 
none of these diseases has the specific organism been determined. When 
it shall have been, its detection will enable us to state definitely what 
disease we have to deal with, and even in the atypical cases of measles 
we shall be able to decide whether it is a case of true measles or 
some disease such as rubella, which closely simulates its irregular 
forms. The following table presents the chief points of differential diag- 
nosis in the exanthemata : 

TABLE 68. 





Scarlet Fever. 


Measles. Rubella. Variola. 


Varicella. 


Incubation 


4 days. 


10 days. 


21 days. 12 days. 


17 days. 


Prodromata .... 


2 days. 


3 days. 


A few hours. 


3 days. 


A few hours. 


Efflorescence . . . 


Erythema. 


Papules. 


Papules. 


Macules. 
Papules. 
Vesicles. 
Pustules. 


Vesicles. 


Desquamation . . 


Lamellar. 


Furfuraceous. 




Large crusts. 








Complications 
and sequelae . . 


Kidnev. 
Ear. 


Eye. 

Lung. 
Tuberculosis. 




Larynx. 
Lungs. 




Heart. 







In addition to the leading points which are indicated in the table, 
the general symptoms, the topography, and the temperature of these 
diseases distinguish them from each other. 

The slow progressive development of variola is very distinct from the 
acute, rapid course of all the others. The vomiting and sore throat of 
scarlet fever are usually quite distinct from the coryza, lachrymation, and 



SPECIFIC INFECTIOUS DISEASES. 613 

cough of measles. In variola the rise of temperature during the pro- 
dromal stage, its decided lessening at the time of the appearance of the 
efflorescence, and its gradual rise again during the stage of suppuration, 
are very distinct from the sudden rise of temperature in scarlet fever 
during the prodromal stage and up to the height of the efflorescence. In 
like manner the temperature in measles differs from that of the other 
diseases in its sudden rise on the first day of the prodromal stage, in its 
lessening on the second day, and in its rise on the third day and up to 
the height of the efflorescence. The manner of the decline of the tem- 
perature differs in variola, in scarlet fever, and in measles. While in variola 
it is slow and prolonged, in scarlet fever it is rather rapid, although it 
declines by lysis, and in measles the fall is often by crisis. In contradis- 
tinction to variola, scarlet fever, and measles, varicella and rubella differ 
markedly in the absence of a prodromal stage, in their short duration, 
and in their evanescent and moderate temperature. 

PAROTITIS. 

Etiology. — Parotitis (mumps) is a highly infectious disease which 
attacks the parotid gland. No specific organism has been determined. 
Its period of incubation is usually from two to three weeks, but cases in 
which the period was only three or four days have been reported. It is 
exceedingly rare in infancy, but Demme has reported a case in an infant of 
three weeks. It is most common between the ages of four and fourteen. 

Symptoms. — The onset of the attack is usually accompanied by a 
sense of chilliness, a rise of temperature, and a sensation of stiffness and 
tenderness about the jaws. This is succeeded by a swelling in the region 
of the parotid gland, which becomes enlarged and tender, rendering deg- 
lutition difficult and often very painful. The disease begins on one side, 
but the other gland is usually involved in a day or two. The infection is 
sometimes confined to the submaxillary glands on one or both sides. 

The duration of an attack of parotitis is from a few days to a week, 
but the infection may last for two or three weeks, and it has been stated 
in some cases to antedate the appearance of the glandular enlargement. 
In boys at the age of puberty the complication of orchitis at times arises. 

Although the symptoms of parotitis are commonly very mild, un- 
usual cases sometimes occur in which the children are quite sick, and 
there have been instances in which the orchitis was of so high a grade 
that acute delirium supervened, and in one case reported by Dukes the 
boy fainted when the orchitis began. Exceptionally, some cases of paro- 
titis are marked by general malaise with little or no pain. Nephritis, 
facial paralysis, deafness of sudden onset and permanent, suppuration of 
the parotid gland, pneumonia, endocarditis, pericarditis, and meningitis 
are rare complications or sequelae of mumps. 

Diagnosis. — It is sometimes difficult to differentiate parotitis from a 
simple non-infectious enlargement of the parotid gland or of the glands 



614 



PEDIATRICS. 



in its neighborhood. When the parotid gland is enlarged it usually shows 
a characteristic swelling under and behind the lobe of the ear, so that the 
lobe is pushed somewhat upward and forward. This swelling increases 
rapidly, is very tender, is not especially reddened, does not fluctuate, and 
is accompanied by constitutional symptoms. The diagnosis is readily 
made if after a few days the unilateral swelling is followed by corre- 
sponding symptoms on the opposite side. 

Treatment. — There is no especial treatment for the disease, as it is 
self-limited and runs a definite course. The children should be carefully 
isolated, in order that there may be no further spread of the affection. 
If the isolation is to be continued until all danger of infection has passed, 
it should be maintained in ordinary cases for three weeks from the onset, 
or, in prolonged cases, until ten days or two weeks after the disappear- 
ance of the swelling. As deglutition is painful, the diet is usually milk 
and soups. The patients should be carefully protected from exposure, 
and should be confined to their rooms. Older children should be con- 
fined to bed, as orchitis in boys and trouble with the mammae in adoles- 
cent girls are less likely to arise under these conditions. It is usually 
better to apply some soft cotton-wool to the painful swelling, and to protect 
it from any irritation. 

Submaxillary Mumps. — The submaxillary glands are enlarged in 
children from various causes. At times the enlargement of the glands is 
accompanied by pain and tenderness, constituting a disease which has been 
called submaxillary mumps. In the beginning, however, we should not at 

once make this diagnosis, as the glands 
may become enlarged and tender from 
various causes which have no connec- 
tion with the specific disease mumps. 

Fig. 129 represents a probable case 
of submaxillary mumps. 

The child, a girl two years and four 
months old, was suddenly attacked with a 
swelling of the submaxillary glands, accom- 
panied by pain and a slight amount of tender- 
ness over the swollen region. She had a his- 
tory of exposure to parotitis. On the follow- 
ing day the swelling had extended under the 
entire chin and up the left side of the neck 
to the face and ear. 

The swelling, pain, and tenderness lasted 
for a number of days and then gradually sub- 
sided. Nothing more definite was discovered 
regarding the case. 
The diagnosis in a case of this kind must be held in abeyance for a few days, and 

strict isolation should be enforced, as, if the cause of the glandular enlargement proves 

to be infectious, other children should be protected. 



Fig. 129. 




Submaxillary mumps. 



DIVISION IX. 

DISEASES OF THE MOUTH, NOSE, EAR, NASO- 
PHARYNX, AND PHARYNX. 



DISEASES OF THE MOUTH. 

Nomenclature. — Much confusion exists as to the nomenclature of dis- 
eases of the mouth. A great variety of names has been used by different 
authors to describe the same disease, so that at times it is quite difficult 
for one investigator to compare his work with that of another. Such 
terms as " canker" and " aphthae" are so commonly used for almost any 
morbid condition of the mucous membrane of the mouth that they have 
ceased to convey any definite idea. 

In order to obviate this difficulty the American Pediatric Society has 
adopted a provisional nomenclature of the diseases of the mouth which 
was prepared by Dr. Forchheimer, of Cincinnati, and myself. To Dr. 
Forchheimer's extended investigations on this subject I am much indebted. 

Diseases of the mouth occur more frequently and in much greater 
variety in infancy and in early childhood than at any later period of life. 
This depends partly on the anatomical conditions at different periods of 
development and partly on the external influences which are brought to 
bear upon the buccal mucous membrane. During the first three or four 
months of life the function of the salivary glands is not developed, and 
the flow of saliva is insignificant. This lack of saliva allows the mucous 
membrane of the mouth to be dry in comparison with that of the older 
subject. Even after the saliva is secreted the infant is more apt under 
certain conditions to let it flow from the mouth than to swallow it, so 
that the mucous membrane of the lips and mouth may present a different 
appearance in young infants, when they are attacked by various morbid 
processes, from that seen at a later period of development. We must 
also remember that the salivary glands in addition to their especial func- 
tion are excretory organs, and that substances which are absorbed by the 
stomach may be eliminated by the mouth and in this way become sources 
of irritation and disease in the latter. The mucous membrane of the 
mouth during almost the whole period of infancy is subject to external 
sources of irritation to which older children, as a rule, are not liable. 
Thus, during the first year the mucous membrane is subjected to more or 
less mechanical irritation through the mechanism of sucking. At this 

615 



616 



PEDIATRICS. 



period, also, it is very common for foreign organisms to be introduced into 
the mouth by means of the ringers either of the infant itself or of its at- 
tendant. It is not surprising, therefore, that we should meet with a great 
variety of pathological conditions in the mouth in infancy. 

The organisms which occur in the mouth are so numerous that very 
few of them have as yet been differentiated in such a way that they can 
be known as the cause of the specific disease in which they are often 
found. We cannot, therefore, at the present time describe the various 
diseases of the mouth under their proper etiological headings, and we are 
forced to adopt provisionally the name of the pathological lesion which 
exists in them. 

In almost every disease of the mouth which occurs in infants and in 
young children there is a coexisting inflammation of the mucous mem- 
brane. This inflammation may at times be very mild and often difficult 
to detect as such, but it still presents a recognizable pathological condi- 
tion. This inflammatory condition, although not necessarily preceding the 
various diseases, yet in a large number of cases either exists as a basis on 
which the disease develops, or so closely accompanies it that the general 
name stomatitis (inflammation of the mucous membrane of the mouth) 
seems to be a proper term to use in connection with all these diseases. 

Under the general heading stomatitis we can speak of most of the 
important diseases which affect the mucous membrane of the mouth in 
infancy and early childhood. These diseases may be divided into four 
general headings, according to the character of the lesions which occur in 
them. 

The following table represents the provisional nomenclature of dis- 
eases of the mouth adopted by the American Pediatric Society : 

TABLE 69. 

f Simplex. 



' Catarrhalis J Exanthematica 



Stomatitis, 



Secondary to the 
Exanthemata, 
f Mechanical. 

Traumatica -J Thermal. 

[ Chemical. 
Herpetica Aphthosa. 



Ulcerosa. 



Mycetogenetica. 



Scorbutus. 

f Arsenic. 
Mineral Poisons .) Lead. 

* i ' ,i -i- I Mercury. 

L And other diseases. 

Hyphomycetica Thrush. 

f Diphtheria. 
Tuberculosis. 
• j Syphilis, 
(_ and like diseases- 
G-angraenosa Noma 



Pseudo-Membranosa. 



DISEASES OF THE MOUTH. 617 

In accordance with this table the four general names which cover all 
these diseases are stomatitis catarrhalis, stomatitis herpetica, stomatitis ulcer- 
osa, and stomatitis mycetogenetica. 

STOMATITIS CATARRHALIS. 

Stomatitis Simplex. — The form of stomatitis catarrhalis which is 
called the simple or erythematous form is commonly seen in young infants 
as a hyperaemic condition of the blood-vessels, causing diffuse redness of 
the whole buccal mucous membrane. This erythematous form is so 
common and so entirely without clinical significance that it may be con- 
sidered as physiological and need only be referred to. 

Stomatitis Exanthematica. — The second form, which is called ex- 
anthematica, is the condition of the mucous membrane which occurs 
secondarily to the exanthemata, and has already been described in con- 
nection with these diseases. It therefore need not be spoken of again. 

Stomatitis Traumatica. — The third form, which is called traumatica, 
is the one which represents the characteristic stomatitis catarrhalis. The 
causes of the traumatic form of stomatitis catarrhalis are very numerous. 
They may be mechanical, thermal, or chemical. 

Mechanical. — Among the most common mechanical causes may be 
cited the irritation produced by rubber nipples, too vigorous cleansing of 
the mouth, injudicious rubbing of the gums during dentition, and local 
irritation from a tooth. 

Thermal. — The thermal form of traumatism may result from the admin- 
istration of food which is too hot. 

Chemical. — The chemical irritation may arise in various ways, as from 
lack of cleanliness in the mouth, with its resulting fermentation, and from 
the elimination of irritating products from the glands apparently con- 
nected in some way with disturbance in the gastro-enteric tract. 

It is probable also that various forms of bacteria or their products 
may cause both mechanical and chemical irritation of the buccal mucous 
membrane. Our knowledge of the bacteriology of the mouth is as yet, 
however, so limited that we can scarcely undertake to describe the relation 
between special forms of bacteria and special lesions of the mucous 
membrane. 

Pathology and Symptoms. — As the lesions which are seen in the mouth 
of an infant with stomatitis catarrhalis during life almost entirely dis- 
appear at death, and as very few post-mortem examinations have been 
made of these lesions, we can speak of the pathology and symptoms of 
this disease together. 

The lesion is essentially an inflammatory one, and occurs in different 
grades. On examining the mucous membrane in these cases it is seen 
that the entire lining of the mouth is intensely reddened, that the tem- 
perature of the mouth is increased, that there is usually a certain amount 
of swelling, and that, although the mucous membrane may be dry under 



618 PEDIATRICS. 

certain circumstances, especially at first, yet, as a rule, there is later 
a hypersecretion of mucus and saliva. The blood-vessels are so dis- 
tended and their walls so weak that the slightest traumatism may cause 
their rupture, and the saliva is frequently mixed with a little blood. In 
older children the mucous membrane may be considerably swollen, espe- 
cially behind the incisor teeth. In addition to this general condition of 
the mucous membrane of the mouth, at times the lips are found to be 
swollen and much reddened. The surface of the mucous membrane 
shows a number of small round prominences, which are the muciparous 
follicles. If complete occlusion of the ducts of these follicles occurs, great 
dilatation of the gland will take place, and a cyst may be formed. This, 
however, is a comparatively rare complication. In connection with the 
disturbance of the glands in the mouth the lymphatic glands are usually 
involved secondarily. 

When the catarrhal condition is at its height the mucous membrane is 
so vulnerable that even slight traumatisms may cause abrasions. The 
most marked symptom of stomatitis is pain. The infant is restless, 
usually has a heightened temperature, and refuses to take its nourish- 
ment. The saliva is acid in its reaction, and when secreted in large 
quantities flows out of the mouth upon the chin and neck, sometimes 
causing considerable irritation. The tongue is dry and white at first, then 
becomes of a grayish color, and as the secretion of saliva increases the 
coating of the tongue is washed off and its surface becomes red. 

Prognosis. — The prognosis of stomatitis catarrhalis is, as a rule, good. 
Although the disease does not run a definite course, yet in most cases 
after a few days the pathological condition improves and the symptoms 
grow less severe. The course of the disease is, however, often lengthened 
by the secondary conditions which arise from the gastric disturbances, 
which may be caused by swallowing the irritating secretions of the mouth. 
In weak, poorly nourished infants who refuse to nurse or to take the food 
which is given them, serious results may arise from a lack of sufficient 
nourishment, so that in these cases the prognosis is always grave. In 
older children the prognosis is very good. 

Treatment. — Although stomatitis catarrhalis may run a favorable 
course without any treatment whatever, yet there are so many causes 
which may prolong its course or give rise to secondary affections that it 
is exceedingly important to treat the disease at once. The indications 
for treatment are to relieve the pain and to allay the irritation of the 
mucous membrane so that a sufficient amount of nourishment may be 
taken by the infant to prevent it from being harmed by a lack of nourish- 
ment or by a secondary disturbance of the gastro-enteric tract. If the 
cause can be ascertained, it should be removed at once. The local appli- 
cation of a one to two per cent, cold solution of bicarbonate or borate of 
sodium in distilled water is indicated. This solution should be used very 
gently every half-hour when the infant is awake, by means of a dropper, 



DISEASES OF THE MOUTH. 619 

and occasionally on a clean swab of absorbent cotton. The infant should 
be systematically fed at regular intervals, whether it resists or not ; and 
if it is not being nursed or will not suck from the nipple, a carefully 
modified milk at a temperature of about 32.2° C. (90° F.) should be ad- 
ministered with a spoon or dropper. There is no necessity for giving any 
drug internally in this disease. 

When the stomatitis proves to be intractable and lasts for more than 
three or four days, the mouth can be gently touched with a cotton swab 
wet with a one per cent, solution of nitrate of silver. This should be 
done once a day, and the mouth washed carefully with cold sterilized 
water after the application. 

When there are any abrasions which show a tendency to extend or to 
form an ulcer, they should be touched with a little nitrate of silver melted 
on the end of a silver probe. These abrasions are often so painful that in' 
themselves they may prevent the child from taking its food, and after they 
have been treated with the nitrate of silver the child will often again take its 
nourishment readily. The following case represents stomatitis catarrhalis : 

An infant, six months old, was reported to have been always healthy, and to have 
been nursed by its mother. It cut its first tooth, a middle lower incisor, when it was 
five months old. Nothing abnormal was noticed about the infant until it became fret- 
ful, restless, had a heightened temperature of about 38.8° C. (102° F.), and vomited 
occasionally. Although it did not cry a great deal, it frequently whimpered, as though 
in pain, and kept putting its fingers to its mouth. A few days later it refused to nurse. 
When it was put to the breast it appeared to be hungry and would take hold of the 
nipple vigorously, but immediately afterwards would draw its head away, as though 
sucking the nipple caused pain. 

A physical examination showed nothing abnormal except in the mouth. The 
mucous membrane of the mouth, tongue, and gums was reddened, and small raised 
spots were seen corresponding to the positions of the muciparous glands. The mucous 
membrane of the tongue and lips was somewhat swollen and hot, and evidently sensi- 
tive to the touch. Where the tooth touched the tongue the inflammatory condition was 
especially marked, and it was possible that the sharp edge of the tooth was the original 
starting-point of the general inflammation. 

In the above case the indications were for active treatment, as the infant 
was losing in weight from lack of sufficient nourishment. When the 
mouth is in this condition there is also a great liability to other diseases 
being implanted upon it, as the mucous membrane is very vulnerable when 
a pronounced stomatitis catarrhalis is present. The saliva flows from the 
mouth in such quantities and is so irritating that an eczematous condition 
is likely to be produced on the chin. The following prescription will be 
found useful in such cases : 

Prescription 82. 
Metric. Apothecary. 



Gramma. 



R Sodii boratis 1 

Glycerini 7 

Aq. destil ad 120 



R Sodii boratis gr. xxx 

Gb 



o irivcenni 



3 11 ; 

00 Aq. destil ad Jiv. 



M. M. 



620 PEDIATRICS. 

This should be applied every hour while the child is awake. The 
chin should frequently be dried gently and a little vaseline applied if there 
is any eczema. If the infant is unwilling to nurse because of the stoma- 
titis, the milk should be given by means of a dropper regularly every two 
hours until it will again take the breast. Improvement should be ex- 
pected within four or five days. 

STOMATITIS HERPETIOA. 

The name herpetica has been adopted for the next form of stomatitis, 
because it seems to represent most nearly the lesion which is seen on the 
mucous membrane, although it is not definitely settled that it is a true 
herpes. 

The disease consists of a catarrhal stomatitis in the course of which 
certain lesions resembling sub-epithelial vesicles surrounded by areolae 
occur irregularly and in different parts of the entire buccal cavity. This 
form of stomatitis has usually been known as stomatitis aphthosa (&<pda, an 
eruption or ulceration). This name was given to it by Bohn as distinctive 
from the other forms of stomatitis, but it does not represent the affection 
especially well. 

Etiology. — As a rule, when the mucous membrane of the infant's 
mouth is in a normal condition it is not readily affected by the various 
irritants which produce its special diseases. When a catarrhal condition 
is present the mucous membrane becomes more vulnerable and the various 
diseases have an opportunity to develop. This apparently is illustrated 
in the case of stomatitis herpetica, in conjunction with which affection a 
catarrhal stomatitis is always found. No cause, either local or general, 
has as yet been determined for this disease. Various micro-organisms 
have been observed in the mouth when it is affected by stomatitis her- 
petica, but no actual connection has been discovered between them and 
the disease. This affection may be found associated with a number of 
other diseases, but usually occurs alone. It does not seem to be con- 
tagious, nor to be especially connected with diseases of the gastro-enteric 
tract or with dentition, although it very commonly occurs during the 
dental period. It appears to be the result of certain deleterious influences 
which act upon the nerve-centres and produce an herpetic efflorescence 
on the mucous membrane which corresponds closely to that which is 
seen in herpes on the skin. 

Pathology and Symptoms. — In addition to the usual lesions of a stoma- 
titis catarrhalis, spots, not necessarily symmetrical or unilateral, of different 
sizes and of different shades of white or grayish white, appear in various 
parts of the mouth, especially on the inner surface of the lip, on the side 
and under surface of the tongue, and on the gums. These lesions do 
not affect the follicles of the mouth, and the efflorescence cannot be 
called follicular, as it is closely connected with the muciparous glands. 
The lesions make their appearance with great rapidity, and develop very 



PLATE XI. 







Stomatitis Herpetica 
( Aphthosa.) 



Stomatitis Ulcerosa 
^Scorbutus.) 





Follicular Tonsil litis. 



Diphtheria. 



DISEASES OF THE MOUTH. 621 

quickly from a macule into what is supposed to be a vesicle. The action 
of the secretions of the mouth upon these lesions necessarily prevents 
them from having the same definite appearance that they would present 
on the skin. The course of the disease so strongly simulates that of 
herpes that at present it would seem wise to consider the efflorescence 
herpetic. 

The general appearance of the efflorescence when at its height is that 
of a sub-epithelial vesicle, somewhat glistening, of a whitish-gray color, 
and surrounded by a red areola. The lesions may be only a few in 
number, scattered irregularly over the parts of the mucous membrane 
which I have already described. At times, however, the efflorescence is 
very diffuse, sometimes appearing as minute grayish points, which may 
become much larger and cover the mucous membrane so thickly as 
almost to simulate a false membrane. In a still later stage of the disease 
these lesions may break down and form small superficial ulcers. 

An infant or young child affected by stomatitis herpetica presents a 
very characteristic appearance. It looks dull and apathetic, and wishes 
to lie quietly in bed. It usually has a heightened temperature, and evi- 
dently suffers from pain and heat in its mouth. The saliva flows from 
the mouth in large quantities, and often irritates the chin and neck to such 
an extent that an eczematous condition results. The child refuses to take 
its nourishment, and is very fretful and restless. These symptoms con- 
tinue for four or five days or a week, and sometimes extend over a period 
of two weeks, the disease then disappearing of itself; in fact, it appears 
to be self-limited. Unless the lesions of stomatitis herpetica are compli- 
cated by those of stomatitis ulcerosa, the saliva is never fetid. 

Prognosis. — The prognosis of stomatitis herpetica is very favorable, 
although infection from other diseases may take place. This latter occur- 
rence is, however, exceedingly rare. Relapses are very uncommon in 
this form of stomatitis, and the lesions usually heal readily. 

Treatment. — There is no internal treatment which is of benefit in this 
disease. The indications for treatment are to allay the irritation of the 
mucous membrane and to prevent its infection by some other poison. 
The mouth in general should be treated as has just been recommended 
in the case of stomatitis catarrhalis. As a rule, very little treatment is 
necessary beyond occasionally cleansing the mouth with the solution 
(Prescription 82, page 619) already mentioned. The ulcers which do not 
heal readily can be touched with nitrate of silver. The feeding should 
be at regular intervals and if necessary forced. 

Plate XI., facing page 620, represents stomatitis herpetica in a boy four years 
old. He was perfectly well until two days previous to the appearance shown in the 
plate ; he then began to be feverish, was restless at night, refused to take his food, 
and seemed quite sick. On the following day the entire mucous membrane of the 
mouth was found to be affected with stomatitis catarrhalis, and somewhat later the 
herpetic form of stomatitis, the lesions of which are shown in the plate. 



622 PEDIATRICS. 

On drawing down the lower lip on the right side a number of small grayish-white 
spots surrounded by a somewhat deeper, reddened mucous membrane were seen. At 
a little distance from them, on the left side of the lip, close to the gum, was appar- 
ently a sub-epithelial vesicle. On the inner side of the lower gum one of these vesicles 
had broken down, and a small superficial ulcer covered with a grayish- white exudation 
was seen. There were also lesions of the same vesicular character along the left edge 
of the tongue. The entire mucous membrane of the mouth was intensely reddened, 
and the case illustrated stomatitis catarrhalis as well as stomatitis herpetica. 

The child absolutely refused to take food, and so it had to be forced upon him. 
In a few days the more severe stage of the disease passed away and he took his food. 
The treatment was to bathe the inflamed mucous membrane with cold sterilized water, 
and small quantities of an alkaline modified milk were given to him. As this child 
appeared lying with his eyes half closed, with flushed cheeks, in an apathetic con- 
dition, occasionally whimpering as if in pain, and with the saliva flowing contin- 
uously from his mouth on the pillow, one could readily diagnosticate the disease 
stomatitis. When, in addition, the characteristic lesions of the mucous membrane 
irregularly distributed throughout the buccal cavity are noticed, and no evidence of a 
membranous exudation can be found, there need be no doubt as to the diagnosis. In- 
ternal remedies are not needed in a case of this kind. Chlorate of potassium, which 
is so commonly used in all diseases of the mouth, is not indicated in the forms of 
stomatitis which have just been described. 

In connection with this form of stomatitis may be mentioned certain 
lesions occurring in the mouths of new-born infants which have been 
called Bednar's aphthce. These lesions consist of -small superficial ulcers 
usually having a grayish coating, and appearing on the posterior part of 
the hard palate and on the soft palate. They are now supposed not to 
represent a specific disease, but to be the result of traumatism, such as 
may arise from a badly-shaped rubber nipple or from undue violence in 
washing the mouth. 

They are to be treated as any local irritations of the mouth should 
be, — namely, by removing the cause, applying a solution of bicarbonate 
of sodium, and, if necessary, touching them with nitrate of silver. 

STOMATITIS ULCEROSA. 

By stomatitis ulcerosa we mean a peculiar pathological process of the 
mucous membrane of the mouth occurring only when there are teeth 
and affecting the gums around the teeth. 

Etiology. — This affection of the mouth may occur in the course of a 
number of diseases, notably in scorbutus. It may also be produced by 
the internal administration of such mineral poisons as arsenic, lead, or 
mercury. Occasionally it may occur as a local affection without known 
cause, but it is probably produced by the irritation of some form of micro- 
organism not yet determined, although the pyogenic bacteria are very 
commonly present. 

The most common form of stomatitis ulcerosa produced by the mineral 
poisons is that which is seen in connection with mercurial salivation. 

As in the other forms of stomatitis, it is probable that the mucous 
membrane is first affected by a catarrhal process which renders it vul- 



DISEASES OF THE MOUTH. 623 

nerable to the special irritation which produces stomatitis ulcerosa. This 
preceding stomatitis catarrhalis may be produced directly by local irri- 
tation in the mouth itself, or may be the result of some disturbance of 
the general system. For this reason stomatitis ulcerosa, as a rule, does 
not affect primarily a healthy individual. Thus, a poorly nourished child, 
and one whose mouth is not properly cared for, will be more apt to have 
this disease develop than one who is correctly fed and whose mouth is 
clean. 

Pathology. — The pathological condition is one of necrobiosis ; that is, 
there is softening as well as death of the tissues. The disease, although 
starting in the mucous membrane, may extend to the periosteum, and 
even produce necrosis of the bone. It begins at the free border of the 
gums, and can extend in all directions, but it never passes beyond the 
mucous membrane of the mouth. The softening of the tissue not only 
changes its consistency but also renders it more movable, and in this way 
the gums at times become so swollen and loosened that they may entirely 
cover the teeth. 

Symptoms. — Stomatitis ulcerosa is usually preceded by moderate consti- 
tutional symptoms, such as fever, loss of appetite, and fretfulness. The 
mucous membrane of the gums at the free margin of the teeth becomes 
reddened and soon begins to swell. The normal curve of the gum be- 
comes almost a straight line and covers the lower part of the teeth. The 
gums in the space between the teeth remain unaltered at first. The 
mucous membrane then begins to change in color and becomes purplish. 
Extreme congestion and softening of the tissues allow hemorrhage to 
take place from the slightest pressure. Although the anterior surface of 
the gums is most commonly affected, yet in severe cases the posterior 
surface is also involved. As the process develops further the gum be- 
comes more and more loosened as it extends over the teeth. A muco- 
purulent secretion collects between the gums and the teeth and causes a 
fetid odor. According to Forchheimer, a yellowish seam then appears at 
the top of the swollen outline of the gum. This is due to the molecular 
destruction which has already begun. This seam is at first very narrow, 
but later it may become broader and involve almost the whole of the 
gum. In connection with this characteristic appearance of the gums 
there is a great hypersecretion of saliva. At the height of the disease the 
child evidently suffers from pain in the mouth, cries a great deal, and 
rapidly emaciates. The lymphatic glands are usually swollen, and remain 
so until the disease has ended. When the yellowish material which con- 
stitutes the seam already referred to is removed, an ulcerated surface will 
be found beneath. Although stomatitis ulcerosa may begin about any of 
the teeth, its most common starting-point is around the lower incisors. 
As the disease improves, the gums gradually become less swollen and 
congested, returning to their normal relation to the roots of the teeth, 
and the salivation disappears. 



624 PEDIATRICS. 

Diagnosis. — The differential diagnosis of stomatitis ulcerosa, when the 
lesions of the disease are marked, presents no difficulty. Although an 
herpetic efflorescence may occur coincidently with the ulcerative form, 
yet the pictures of the two diseases are so different that we know at once 
that we are dealing with two affections rather than with one. There is 
no other disease of the mouth in which the gums assume the purplish 
hue and the swollen, soft, and loosened condition which are character- 
istic of stomatitis ulcerosa. 

Prognosis. — The prognosis of stomatitis ulcerosa depends upon its 
cause and whether it is treated or not. The tendency is, however, after 
a variable period of discomfort to the child, for the disease to disappear. 

If the affection is the result of one of the constitutional diseases, such 
as syphilis or scorbutus, it disappears if the treatment of the specific 
disease is beneficial, otherwise it continues, and may finally lead to death 
by exhaustion. 

Treatment. — The local form of the disease is best treated by the 
internal administration of chlorate of potassium or by this drug in 
solution used as a wash for the mouth. Chlorate of potassium must, 
however, be given with great precaution to infants and children, as in 
certain cases it acts as a poison, some infants being affected by even 
minute doses. The symptoms which show that chlorate of potassium is 
producing deleterious effects in infants who are most likely to be affected 
by the drug are drowsiness and suppression of urine, Avith weakness of 
the heart and sometimes cyanosis. When these symptoms follow the 
administration of the drug, it should be omitted at once and a simple 
wash of borate of sodium used. Chlorate of potassium when given in- 
ternally has been found to be secreted in the saliva within five or ten 
minutes, and thus has an opportunity of producing a direct effect upon 
the lesions of the gums. The doses of chlorate of potassium, which, it 
has been found, can be safely administered to infants and children, should 
be remembered when prescribing the drug. Table 70 gives the minimum 
doses which can safely be taken in the twenty-four hours at different ages, 
and which are sufficient to produce the specific effect of the drug in treat- 
ing cases of stomatitis ulcerosa. 

TABLE 70. 

Amount of Chlorate of Potassium which can be safely given in Twenty-four Hours at 

Different Ages. 
Age. Gramme. 



Under 1 year 1 

1 to 2 years 1 

2 to 6 years 2 

6 to 8 years 2 

8 to 14 years 3 



In order that the chlorate of potassium shall produce the best effects 
it should be given frequently. The total amount for twenty-four hours 



DISEASES OF THE MOUTH. 625 

which is to be given at any special age is to be placed in a tumbler and 
dissolved in as many tablespoonfuls of sterilized water as there are doses to 
be given within the twenty-four hours. Let us suppose that the number 
of hours which the child sleeps is ten : then fourteen tablespoonfuls of 
the solution should be prepared, and the child should be given one table- 
spoonful every hour when it is awake. The administration of chlorate of 
potassium at first usually produces considerable smarting and pain in the 
mouth as it passes over the inflamed surface of the mucous membrane. 
These symptoms, however, last for only a short time, usually disappearing 
entirely after thirty-six to forty-eight hours. 

Under this treatment the disease is ordinarily cured in a week or ten 
days. The treatment should, however, be continued for a number of 
days after the mouth is apparently entirely well. 

When deeper ulceration has taken place, its disappearance may some- 
times be expedited by the application of nitrate of silver. When a se- 
questrum has formed, it must be removed. Frequent washing of the 
mouth with sterilized water administered by means of a dropper is also 
very important, especially after the taking of food. An alkaline diet is 
indicated. 

Plate XL, facing page 620, represents a case of stomatitis ulcerosa in an infant 
ten months old, in whose mouth were shown the characteristic lesions of the disease. 
In this case the disease happened to be secondary to scorbutus, the affection for which 
the infant was treated. 

The infant had six teeth, and the mucous membrane was affected only at the junc- 
tion of the gums with the free surface of the teeth. The other parts of the mucous 
membrane of the mouth were reddened, but not markedly so. The portions of the gums 
affected were swollen, purplish, loosened, and almost covered the teeth. There was a 
considerable flow of saliva, with a fetid odor from the mouth. An appearance of this 
kind is diagnostic of stomatitis ulcerosa. 

The following case of stomatitis ulcerosa was apparently of local 
origin : 

A girl, three and a half years old, had always been healthy, and had had no 
diseases of any kind. She began to have loss of appetite, a temperature varying from 
38.3° to 39.4° C. (101° to 103° F.), and to be very fretful. Three days later the 
gums were noticed to be swollen, to be of a dark-red color, and her breath had a fetid 
odor. She was rather apathetic and wished to remain in bed. There was considerable 
salivation. During the first three days her restlessness was so excessive at night that 0.3 
gramme (5 grains) of bromide of potassium had to be given to her to produce sleep. 

In two or three days more the disease ran its course, and entire recovery took place. 

STOMATITIS MYCETOGENETICA. 

There are three forms of vegetable parasites which occur in or upon 

the human body : (1) bacteria, or fission-fungi (schizomycetes) ; (2) yeasts, 

or yeast-fungi (saccharomycetes) ; (3) moulds, or mould-fungi (hyphomy- 

cetes). The changes in the tissues which are due to fungi are termed 

40 



626 PEDIATRICS. 

mycetogenetic metamorphosis, and thus the pathological conditions in the 
mouth which are produced by any of these forms of fungi may be 
designated by the general term mycetogenetiea. Under this general head- 
ing of mycetogenetiea we can include the various forms of stomatitis 
which are caused by fungi. 

Stomatitis Hyphomycetica (inrush). — Etiology. — The disease which 
is commonly called thrush is produced by a fungus which finds its nidus 
upon the surface of the mucous membrane of the mouth, usually in 
young infants. This fungus was formerly supposed to be the o'idium albi- 
cans, but it is now known not to be this organism, and the precise form 
of mould which it represents has not yet been determined. We merely 
know that this growth of thrush is one of the mould-fungi, and we can 
therefore at present only classify it as stomatitis hyphomycetica. 

The moulds are complex in their structure, and as commonly de- 
scribed consist of a series of delicate jointed threads (mycelium) in which 
spores are developed. Hyphomycetic growth is characterized by having 
the spores naked on conspicuous threads. The fungus of thrush may be 
found on any of the mucous membranes of the body. It has also been 
found in various organs, as in the brain and the lungs, and from the 
surface of ulcers it has on rare occasions penetrated the blood-vessels 
and given rise to visceral metastases. The usual place for it to appear, 
however, is the mucous membrane of the mouth. It is a local disease, 
and may occur in the mouths of healthy children as well as in those 
who are diseased. It is more likely, however, to be ingrafted upon a 
diseased than upon a healthy mucous membrane, in accordance with the 
rule which I have already stated. A catarrhal condition of the mucous 
membrane, by displacing the epithelial cells and thus interfering with their 
protection of the mucous membrane, affords the readiest means for the 
development of the fungus of thrush. It is therefore more likely to be 
found in the mouths of children who are suffering from various diseases 
or who are ill cared for. It may be carried to the mouth in various ways, 
either on dirty nipples or by the finger. 

Pathology. — The growth may take place on both squamous and 
cylindrical epithelium. According to Forchheimer, the first lodgement of 
the fungus comes between the epithelial cells of the mouth, and from 
this the growth works its way under the free surface of the mucous mem- 
brane. When directly on the free surface the growth is not so luxuriant 
and is principally in the mycelium form. In the case of a mucous mem- 
brane lined by flat or squamous epithelium, the growth is facilitated by 
the relation of the cells to one another. In a membrane lined by cylin- 
drical epithelium, the growth takes place, but not so readily, because there 
is but one layer of cells. After the first development the growth goes 
on very rapidly, and after it has found a nidus the cells are pushed aside 
and are surrounded by mycelium, the whole presenting the characteristic 
appearance of thrush. The growth begins in small spots, sometimes one, 



DISEASES OF THE MOUTH. 627 

sometimes more, and at times the entire surface of the mucous membrane 
is covered with it. The fungus develops within the epithelium, and it 
requires considerable rubbing to remove the growth. 

Symptoms. — An attack of thrush usually begins with local symptoms 
of catarrhal stomatitis. At times, however, no symptoms are present, 
the fungus being the first abnormal condition which is noticed. The 
appearance of the fungus resembles closely that of curdled milk, though 
it is often of a rather grayish color. It does not look like a membranous 
exudation, but is raised in small patches above the level of the mucous 
membrane. The fungus usually develops on the inner borders of the 
lips, on the gums, on the tongue, and on the hard and the soft palate. It 
may extend to the tonsils and pharynx, and even into the oesophagus. In 
the latter locality at times it has been found to grow so thickly that the 
lumen is almost entirely occluded. The local symptoms are commonly 
those of a mild catarrhal stomatitis. The general symptoms depend upon 
the extent of the local disease from which the infant is suffering. Infants 
affected with this disease soon become atrophic, from a lack of proper 
nourishment, as they are often unwilling to take their food or cannot 
swallow it without difficulty. . 

Diagnosis. — The differential diagnosis is seldom difficult to make. 
Curdled masses of milk on the inner surfaces of the lips and on the 
gums may resemble closely the fungus of thrush, but the former is easily 
wiped away, while the latter is difficult to dislodge. The disease is 
definitively determined by placing some of the growth under the micro- 
scope, where it presents characteristic appearances. 

Prognosis. — The prognosis of thrush varies according to the general 
condition, the vitality, and the age of the subject on whom it is en- 
grafted. The disease may last indefinitely if the mouth is not carefully 
treated, and its prolongation may render the prognosis more grave. When 
the growth is very extensive, as in the cases in which it has invaded the 
oesophagus, the prognosis is very unfavorable. In these cases disturbances 
of the gastro-enteric tract are apt to arise and to increase the likelihood 
of a fatal issue. As a rule, however, if the infant's health can be main- 
tained, and if the local treatment is carried out thoroughly, the prognosis 
is favorable. 

Treatment. — The treatment should be directed to the local care of the 
mouth and to supporting the strength by proper nourishment and stimu- 
lants until the fungus has been eradicated. Care should be taken that 
everything connected with the infant, especially the nipples and bottles 
from which it is to be fed, should be aseptic, so that it shall not be con- 
tinually reinfected or infect other children. The mouth after each feeding, 
and also between the feedings, should be thoroughly and somewhat vig- 
orously rubbed with the solution which has already been recommended in 
the treatment of stomatitis catarrhalis. 

When the disease is in the oesophagus it is best treated by the intro- 



628 



PEDIATRICS. 



duction of a soft rubber tube, in order that the growth may thus be me- 
chanically separated from the mucous membrane. 

In many cases the disease is very intractable. No special drug appears 
to be of use in these cases, and they can be cured only by the unremitting 
and patient removal of the growth as just described. 



Plate XL, facing page 620, Thrush, represents the mouth of an infant three 
months old, who refused to take the bottle for a month, was emaciated and fretful, 
and at times vomited. 

A careful physical examination failed to detect anything abnormal except in the 
infant's mouth. On gently depressing the tongue and lower jaw, it was seen that the 
soft and the hard palate, the tongue, the gums, and the inner surface of the lips were 
covered almost entirely with white and grayish-white masses, in texture somewhat re- 
sembling curdled milk, and rising above the level of the epithelium. Between these 
patches the mucous membrane was reddened. There was a moderate flow of saliva. 
This morbid growth apparently did not extend into the pharynx. The patches could 
not be removed readily, as would be the case if it were curdled milk, and the growth 
evidently passed between the epithelial cells down to the underlying mucous mem- 
brane, where it was held so closely that it required considerable rubbing to separate it. 
In this case the growth was so extensive that it simulated a membrane in some places, 
but its generally roughened surface, its elevation above the level of the mucous mem- 
brane, and the characteristic appearances in other parts of the mouth rendered its 
recognition quite simple. 

On placing some particles of this growth in glycerin under the microscope a 
tangled mass of fine, almost translucent, membered threads were seen as represented 
in Fig. 130. 

Fig. 130. 




Mycelium of thrush interspersed with spores and fatty degenerated cells. (Low power Zeiss Oc. 3, 

Objective DD, glycerin.) 

Interspersed among these threads were bright, glistening, oval bodies, which were 
the formed spores, and also fatty degenerated cells and fine detritus. This combi- 
nation of appearances represents the pathological processes which we find in thrush. 



DISEASES OF THE MOUTH. 



629 



Fig. 131 represents some shreds from the same specimen, but much more highly 
magnified. In this specimen can be seen the formation of the spores in the mycelium. 

Fig. 131. 




Thrush showing the formation of spores in the mycelium. (Zeiss Oe. 3, homogen. immer. 2.0 mm. 



Stomatitis Pseudo-Membranosa. — Under this heading I shall merely 
refer to those pseudo-membranous conditions which occur in diphtheria, 
tuberculosis, syphilis, and diseases of a like class. The former two are 
so rarely seen in the mucous membrane of the mouth that it is not neces- 
sary to describe them. The lesions which occur in the mouth in syphilis 
have already been described when speaking of that disease. 

Stomatitis G-angrsenosa (noma, cancrum oris). — Stomatitis gangre- 
nosa is the rarest and most fatal form of stomatitis which occurs in 
children. It is usually met with between the ages of three and seven 
years. It is a disease characterized by a gangrenous process which begins 
on the gums or on the inner surface of the cheek and spreads with great 
rapidity to the adjoining tissues, all of which can be involved and quickly 
destroyed 

Etiology. — It is probable that there is a specific germ Avhich causes this 
disease. This organism has, however, not yet been determined. It is 
supposed that it does not attack a healthy mucous membrane, and that 
one of the other forms of stomatitis, especially stomatitis catarrhalis, and 
in some cases stomatitis ulcerosa, precedes it. Furthermore, stomatitis 
gangrsenosa seldom attacks healthy children, but usually affects those who 
have other diseases and are greatly debilitated. It occurs most commonly 
secondarily to the acute exanthemata, especially measles. The disease is 



630 PEDIATRICS. 

also said to result from the administration of mercury in too large 
doses. 

It begins as a reddened, hard spot in the mucous membrane, usually 
of the cheek. This soon becomes gangrenous and extends rapidly through 
the entire thickness of the cheek, producing perforation. It may also extend 
laterally in all directions, attacking the bone as well as the other tissues. 

Symptoms. — The first symptom which is apt to be noticed is the gan- 
grenous odor which comes from the mouth. On examination an ulcer 
will be found which tends to spread rapidly. The cheek becomes much 
swollen, is hard and cedematous, the oedema especially affecting the 
tissues under the eye. The gangrenous process extends very rapidly, 
at times destroying large portions of the face, and also involving the 
bones, which become denuded. The teeth become loose and fall out. 
The odor from the gangrenous tissue is excessive. The flow of saliva is 
very much increased. The degree of suffering which the children 
undergo varies very much ; sometimes it seems as if they suffered no 
pain whatever. The temperature varies, at times being raised and again 
being subnormal. The pulse is weak and rapid. The appetite is dimin- 
ished, and the children are likely to have diarrhoea, probably due to the 
infectious nature of the products of the mouth which are swallowed. 
Hemorrhages are rather rare, according to Forchheimer, as the blood- 
vessels are usually filled with thrombi. Secondary affections, such as 
catarrhal pneumonia from the inhalation of septic material, are not un- 
common. The child may die from one of these secondary affections, or 
it may become more and more weakened by the local condition, and 
unless the morbid process is arrested it will die eventually from ex- 
haustion. 

Diagnosis. — The diagnosis of this disease, except in its earlier stages, 
is not difficult. At times, however, a local ulcerative process produced 
by a decayed tooth may simulate closely stomatitis gangraenosa. In these 
cases the diagnosis is made more difficult by the fact that the tissues of 
the cheek may become hard and look as though perforation might take 
place. Coincidently with this condition the ulceration of the gum and 
often of the mucous membrane of the cheek, with the foul odor which 
emanates from it, makes the similarity of the two diseases very striking. 
In simple ulceration from a tooth, however, active local treatment with 
solutions of myrrh or of soda combined with frequent washing of the 
mouth with sterilized water is soon followed by marked improvement, 
while when stomatitis gangraenosa is present the morbid process con- 
tinues to extend. 

Prognosis. — The prognosis in cases of stomatitis gangraenosa which 
are untreated is almost universally fatal. Cases have been known, how- 
ever, in which a line of demarcation has formed around the gangrenous 
spot, granulations have arisen, and cicatrization has followed, leaving 
extensive scars. If the disease is treated by extirpation of the diseased 



DISEASES OF THE MOUTH. . 631 

tissues in the very beginning, the prognosis becomes more favorable. 
When the disease has perforated the cheek and the gangrenous process 
has become extensive, the child is seldom relieved even by surgical 
treatment. 

Treatment. — Care should be taken when a child is affected with a 
disease of an exhausting nature that its mouth is kept thoroughly cleansed, 
for we can never tell when or in what individual the mucous membrane 
may become vulnerable to the organism which produces stomatitis gan- 
grenosa. In stomatitis gangrenosa it is very important for the success 
of the treatment that it should be begun very early in the disease. When 
the diagnosis has been definitely made, it is wiser not to temporize with 
applications of nitrate of silver and other drugs, but at once to place the 
case in the hands of a surgeon and have the entire area of the invaded 
tissues excised. It is also well after the gangrenous process has been 
removed by the knife to destroy an area of healthy tissue by means of 
the Paquelin thermo-cautery or by the galvano-cautery. There should 
be no delay in operating upon these cases, as great destruction of the 
tissues may take place in even a few hours. 

After the operation the tissues should be inspected frequently, to see 
whether there is any return of the gangrenous spots, and, if found, these 
spots should be removed immediately. As the disease is very apt to 
recur, plastic operations to obviate deformity should not be undertaken 
very early after the operation. 

In treating these cases surgically it must be remembered that the 
child is in a very debilitated condition, and that if it is suffering from any 
especial disease treatment directed to that disease is indicated, also that 
stimulants are required to prevent the already weakened child from dying 
of exhaustion following the operation. 

The following case, a girl four years old, represented in Fig. 132, was 
brought to the hospital to be operated on for stomatitis gangrenosa. 

In this case the disease was apparently primary, and began on the left side of the 
mucous membrane of the mouth. It spread rapidly, and, although treated by local 
applications to the mouth of various solutions, had broken through the left cheek 
close to the ala nasi. The teeth were loose in the middle of the upper jaw, and there 
was a certain amount of alveolar necrosis. There was a strong gangrenous odor 
from the mouth and the tissues of the cheek, and a considerable flow of saliva. The 
child's general condition was fair, but she was becoming more debilitated, had lost her 
appetite, and had a slightly raised temperature. 

The cheek was operated on the day after the child entered the hospital. The 
wound healed readily. One year later the child again returned to the hospital. The 
right cheek was found to be much swollen and indurated, especially under the right 
eye. The periosteum of the lower jaw on the right side was affected, and the necrotic 
process had undermined the whole cheek as far as the orbit. The child was again 
operated on without any external opening of the cheek. The wound healed, and the 
child was discharged from the hospital, but returned some months later with a spon- 
taneous opening on the right cheek. This was again apparently cured by operation. 
Two months later the child was found to have in the lower jaw a process similar to 



632 



PEDIATRICS. 



that which had occurred in the upper jaw. Her health was poor, she was pale and 
weak and had loss of appetite. She was operated upon again, and a sequestrum was 
removed from the lower jaw. She then improved. Some months later she was ap- 
parently in fair health. 

Fig. 132. 




Stomatitis gangrenosa, left cheek. Female, 4 years old 



The microscopic examination of the gangrenous tissues removed at the operation 
presented nothing significant of any especial disease, and a culture showed only a few 
streptococci. 

Fto. 133. 




Stomatitis gangrenosa secondary to measles and pneumonia. Female, 5 years old. 

The following case of stomatitis gangrenosa occurred in a girl five 
years old : 

The disease was preceded by pertussis, measles, and a broncho-pneumonia. 
After she had had the pneumonia for seventeen days her right cheek began to swell and 
a bad odor came from her mouth, but nothing especial could be found in the mucous 
membrane of the buccal cavity. Four days later the swelling of the cheek had much 



DISEASES OF THE MOUTH. 633 

increased, and there was oedema of the lips and eyelid so that the right eye was partly 
closed. The swelling was semi-fluctuating. The temperature varied from 38.3° to 
39.4° C. (101° to 103° F.), and the cough had much lessened. On the following day 
a bluish-black spot about 1.5 cm. (f inch) in circumference appeared at the right cor- 
ner of the mouth, and this rapidly increased during the day. Two days later the dark- 
colored area had increased considerably in size and presented a circular outline with a 
clearly marked line of demarcation. 

The child also had a profuse greenish diarrhoea. On the following day the dark 
area rapidly extended, and soon involved the whole of the right cheek, the right side 
of the mouth, and the right nostril. There was no external loss of tissue. The child 
was extremely emaciated, and from the beginning of the attack was in a hopeless con- 
dition, so that radical treatment of the disease was deemed inadvisable. It died 
suddenly on the following day. Fig. 133 represents the case. 



GLOSSITIS. 

Glossitis is so rare a disease in children that the possibility of its 
occurrence only need be mentioned. In this affection there is an acute 
inflammation of the tissues of the tongue, accompanied by fever, enlarge- 
ment of the organ, and considerable pain. There is usually a hyper- 
secretion of saliva, and at times the obstruction to respiration from the 
occlusion of the throat by the greatly enlarged tongue produces somewhat 
alarming symptoms, though, as a rule, not serious ones. 

This disease may be caused by direct injury to the tongue from corro- 
sive substances, by heat, or by the stings of animals, and sometimes 
probably by sepsis. It runs a variable course ; it is not especially seri- 
ous, and tends to recover after a few days. The treatment is purely 
symptomatic. The frequent local application of ice and of ice-cold alka- 
line solutions to the tongue and mouth is indicated. 

LINGUA GEOGRAPHIOA. 

A condition of the dorsum of the tongue is sometimes met with, 
which, for want of a better name, is called lingua geographica, " mappy 
tongue," or " wandering rash." One or more small patches appear on 
the dorsum or side of the tongue, which in a few days may spread and 
coalesce, often covering a large portion of the surface. They diminish 
in size or fade with equal rapidity, to recur at variable periods. The 
patches are red and smooth, and the filiform papillae are absent. The 
rest of the tongue appears normal, except that the papillae on the borders 
of the denuded portions are white and prominent. The etiology of the 
disease is unknown. It occurs almost exclusively in children or in young 
adults who have been subject to it from childhood. It is very benign, 
and gives no discomfort to the child. Its principal importance lies in the 
fact that it is sometimes mistaken for a symptom of some more serious 
disease. No form of treatment has been found useful. It recurs peri- 
odically for months or years, but does not tend to increase in severity nor 
to lead to other diseases. 



634 PEDIATRICS. 

MICROGLOSSIA. 
In some individuals an arrest of development of the tongue produces the 
condition called microglossia, in which the tongue is to a varying degree 
smaller than normal. 

MACROGLOSSIA. 

The opposite condition, macroglossia, in which the tongue is enlarged, 
is more common than microglossia. It is usually a congenital lesion, and 
is especially marked in cretins. The prominent feature of the affection 
is a prolapse of the tongue, which is often enormously enlarged in every 
direction, is usually of a deep violet color, and is covered with a thick, 
whitish coat. The protruded tongue is indented and even ulcerated by 
the teeth, which are often pushed forward and become carious. The 
saliva flows continuously from the mouth, the lower lip becomes thick and 
ulcerated, and the forcing forward of the lip, larynx, and velum palati 
by the weight of the tongue renders suction, mastication, and deglutition 
difficult. The nutrition of the child is thus much interfered with, and 
this interference is one of the most serious results of the disease. This 
condition is not a glossitis, but a deformity which seems to be associated 
with certain other malformations of the body. In these individuals the 
hands and feet are apt to be large, thick, and purplish. 

Macroglossia appears in two forms. One is the fibrous, in which the 
connective tissue is pathologically increased between the muscular fibres. 
The other is a cavernous cystoid degeneration of the interstitial connec- 
tive tissue, by which the resulting spaces come in connection with the 
lymph-vessels, constituting a condition closely resembling cavernous 
angioma, from which it receives its name of lymphangioma cavernosum. 

The disease seldom tends to recover, and the treatment is to give as 
much relief as possible to the great discomfort which arises from it, by 
cleansing the mouth frequently with alkaline solutions. Especial care 
should be directed to the nourishment of the child. In extreme cases 
surgical interference is indicated when the child's respiration and general 
nutrition are affected, and in some cases great improvement is accom- 
plished by the removal of part of the tongue. 

DIFFICULT DENTITION. 

The normal development of the teeth in infancy and childhood is a 
physiological process. The teeth are developed at birth to a certain de- 
gree, and merely increase in size during infancy until they pierce the 
gums and assume their places in the mouth. In many cases the process 
of dentition gives rise to no morbid conditions whatever. The idea that 
dentition occasions the various diseases with which it was formerly sup- 
posed to be associated is an erroneous one. From the fourth or fifth 
month, however, until the completion of dentition in the latter part of 
infancy, various nervous disturbances are so closely associated with irrita- 
tion in the mouth that in this sense dentition may be considered respon- 



DISEASES OF THE MOUTH. 



635 



Fig. 134. 



sible for many of the slight ailments which arise at this period of life. 
The mouth at this time frequently becomes hot, and sometimes dry, 
although there may be a hypersecretion of saliva. There is evidently 
much discomfort in the region of the gums, as the infant is continually 
rubbing them with its fingers and seems to get relief from biting on hard 
substances. Such infants may become much prostrated and may lose 
their appetite, and thus their nutrition may be interfered with, without 
any discoverable cause for these abnormal conditions beyond the general 
nervous irritation which arises from the feeling of discomfort in the mouth 
and head. In the more extreme cases the infant will be so restless at 
night that it scarcely lies still for half an hour at a time, and may spend 
night after night crying out occasionally as though in pain, and knocking 
its head against the sides of its crib, so that in some cases the crib will 
have to be padded. These infants also have 
to be guarded sometimes from knocking 
their heads against the floor or wall, as they 
seem to become almost frantic from the con- 
tinued irritation from which they are suf- 
fering. These symptoms occur with such 
regularity at a time when a tooth is in its 
final stage of development, and cease so 
uniformly when the tooth has attained its 
growth, that the causal relation between the 
tooth and these nervous symptoms seems 
more than probable. This rather indefinite 
clinical association of dentition and nervous 
symptoms is, however, partially explained 
by the analogous symptoms arising from the 
anatomical relationship which exists between 
the roots of the teeth and the ear. It has 
long been noticed that in certain infants, 
during the completion of the development 
of a tooth, symptoms connected with the 

ear will manifest themselves. These symptoms are usually produced by 
a congestion of the blood-vessels of the ear, which is accompanied by 
pain, and sometimes results in inflammation. They are evidently of 
reflex origin. Fig. 134 explains the influences which an irritation of some 
distant part of the economy may exert on the blood-vessels of the ear. 

The general vascular disturbance in the ear, represented either by 
an uncomfortable feeling of fulness or by general pain, may be produced 
in cases of difficult dentition by this close connection between the sensori- 
motor nerves and the sympathetic. According to Woakes, a considerable 
portion of the blood-supply of the membrane of the drum is derived from 
the artery that leaves the internal carotid in the carotid canal and pro- 
ceeds by a very short course directly to its destination. Being thus 




A, sym pathetic ganglion ; B, sen- 
sori-motor nerve ; 0, afferent sympa- 
thetic fibres from sheath of B; D, 
caudate cells ; E, efferent sympathetic 
fibres proceeding to artery/; F, artery 
dilated ; /, normal size of artery beyond 
the sympathetic influence; G, general 
vasomotor centre ; H, H, the dotted 
lines indicating the course of the fibres 
forming the roots of the ganglion in 
the spinal cord to the general vaso- 
motor centre G. (Woakes.) 



636 



PEDIATRICS. 



Fig. 135. 




A, tympanic cavity ; B, otic 
ganglion ; C, tooth ; D, internal 
carotid ; E, tympanic branch ; F, 
auriculotemporal nerve ; G, au- 
ricular branch of auriculotem- 
poral nerve. The dotted line 
connecting B and C represents 
the inferior dental nerve. 



closely connected with a large arterial trunk, this small tympanic branch 
is very favorably situated for a speedy augmentation of its blood-supply. 
The nervi vasorum constituting the carotid plexus at this part of its course 

come largely from the otic ganglion. On the 
other hand, the inferior dental nerve supplying 
the gums and the teeth also communicates with 
this ganglion. 

We thus arrive at a direct channel of nerve 
communication between the source of irritation 
in the mouth and the vascular supply of the 
drum-head. The earache which arises in these 
cases is produced by the vessels of the mem- 
brana tympani, which become greatly distended, 
and the accompanying stretching of the tense 
and sensitive tissue in which this occurs ac- 
counts for the pain. 

Fig. 135 represents the anatomical nervous 
connection between the teeth and the membrana 
tympani. 

It is thus seen that a great many symptoms, 
usually of slight import, but marked enough to 
give much discomfort to the infant, may arise during this period of den- 
tition, when the infant's entire nervous system seems to be in a very 
sensitive condition. 

Gum-Lancing-. — The question of lancing the gums during the period 
of dentition is one Avhich has given rise to much discussion and to very 
diverse opinions. In former times it was erroneously believed that the 
teeth played an important part in almost every disease which occurred in 
early life. It was also supposed that lancing the gum relieved the symp- 
toms of these diseases in some unexplained way. This extreme view 
soon had to be modified, and of late years many observers have come to 
the conclusion that it is never necessary to lance the gums. In cases of 
difficult dentition, however, as just explained, irritation arises very com- 
monly in the later stages of the development of a tooth, and the question 
therefore remains whether this irritation in various parts of the economy, 
notably in the ear, can be relieved by lancing the gum. With regard to 
the question of gum-lancing, it may be said that it should be resorted to 
only under very exceptional circumstances. 

During the dental period two classes of irritation are met with in con- 
nection with the teeth: (1\ irritation of the dental nerves, with symptoms 
of reflex aural disturbance ; and (2) irritation of the gum over the crown 
of the tooth from pressure, with symptoms of local irritation. We here 
have two entirely different conditions. If, when pain or symptoms in 
some other part of the economy seem to arise from dental irritation, we 
find that the gum which covers the crown of the still undeveloped tooth 



DISEASES OF THE MOUTH. 637 

is soft and flat as in other parts of the mouth where a tooth is not about 
to come through, lancing the gums is manifestly absurd, as there is evi- 
dently no reason for making a wound in the mouth. 

The second class of cases, however, although rather rare, must still 
be recognized as distinct in themselves and requiring especial treatment. 
In this class it is very evident that the gum for some reason does not give 
way to the growth of the tooth. Where the gum covers the crown of 
the tooth the tissues are swollen, tense, almost cartilaginous in their feel- 
ing, and hot. When this combination of abnormal conditions is found 
over the crown of the tooth, it can be relieved at once by the lancet. 

Figs. 136 and 137 represent the condition of the gums in relation to the 
teeth in the two classes of cases which have just been mentioned. Fig. 
136 represents the mucous membrane over the crown of the tooth as flat 
and on a level with the rest of the gum. This is the condition of the 





d T* D 

A, tooth in bone socket ; B, jaw-bone ; C, gum, soft, A, tooth in bone socket ; B, jaw-bone ; C, gum, 

not inflamed or swollen ; D, dental nerve. tense, inflamed, swollen ; D, dental nerve. 

gum in the majority of cases of difficult dentition, yet very severe symp- 
toms of disturbance of the ear and cerebral circulation may apparently 
arise in these cases. The symptoms, of course, are very varied, the most 
definite ones being connected with the ear. In this class of cases the 
gum should never be lanced, even for the purpose of bleeding, as the 
mouth is not a fit place for such a procedure. The treatment of these 
cases should be directed to the especial part of the economy from which 
the symptoms arise. For instance, if the ear is affected, the indication is 
to relieve the reflex congestion. This can be done by the instillation 
into the ear of a few drops of an atropine solution, such as in the follow- 
ing prescription : 

Prescription 83. 

Metric. Apothecary. 

Gramma. 

06 R Atropine sulphat gr. i ; 

Glycerini, 
75 Aq. destil aa g i. 



U Atropine sulphat 

Glycerini, 

Aq. destil aa 3 



M. M. 

Sig. — Drops for aural congestion. 

In addition to this, bromide of potassium should be given in repeated 
doses to the extent that is indicated by the especial case. 

In Fig. 137 the mucous membrane covering the crown of the tooth is 
shown to be markedly raised above the level of the gum. In these cases, 
symptoms of local origin and often of great severity arise. The infant 
evidently has extreme pain and tenderness in its mouth. It cries inces- 



638 



PEDIATRICS. 




Gum-lancet. 



santly, and often refuses to take its nourishment, on account of the acute 
pain which it suffers, and also of the tenderness which is produced by the 
least pressure on the gum, so that it may become weak 
and exhausted. There is usually a considerable elevation 
of the temperature, to 38.8° C. and even 39.4° and 40° C. 
(102°, 103°, and 104° F.). Vomiting is not uncommon, 
and there is twitching to such an extent that convulsions 
seem to be threatening, and at times actually occur. 
There are also great restlessness and insomnia. 

In these cases lancing the gum affords immediate re- 
lief. The temperature quickly subsides, the pain and 
general nervous symptoms disappear, and the infant after 
sleeping quietly for an hour or so wakes up and takes 
its food with avidity. The treatment in this class of cases, 
when the diagnosis is once made, is to lance the gum. 
This is done in the following way. The infant is placed 
in the nurse's lap, with its head in the lap of the phy- 
sician, the nurse holding its arms firmly. The physician, 
after having first thoroughly sterilized his hands and 
washed the infant's mouth and gums with sterilized 
water, carefully makes an incision over the swollen gum 
well down to the crown of the tooth. Fig. 138 repre- 
sents the gum-lancet which I am in the habit of using for 
this purpose. As only the end of this lancet is sharp, there is less danger 
of wounding the infant's lips and mouth than with the ordinary bistoury. 
Before using the lancet it should be thoroughly sterilized. 

Although much has been said about the danger of hemorrhage in 
these cases, and of infection of the wound by pathogenic organisms, yet 
instances in which such results have occurred are so exceedingly rare 
that they should not deter us from treating the case properly as we would 
treat an abscess in the mouth, tonsil, or pharynx. It has also been said 
that a cicatrix may form on the gum over the crown of the tooth as a 
result of lancing. This is an exceedingly rare occurrence, and need 
scarcely be taken into account. The probability is that, when such an 
instance has occurred, the case was not one in which the gum should have 
been lanced, and the fear of such a result as this should certainly not 
weigh in the balance against the possible exhaustion and acute pain 
which may continue for days unless relief is given by cutting. 

It must be understood, however, that the first class of cases of difficult 
dentition are by far the most frequent. 
The following case is illustrative : 

An infant, ten months old, was brought to the clinic with the following history : 
It had one lower incisor. At the time when this tooth was about to appear above 
the margin of the gum the infant was very restless, and had considerable fever, and 
pain in its ear. Somewhat later a muco-purulent discharge came from the ear, but 



DISEASES OF THE MOUTH. 639 

the general symptoms of restlessness, pain at times, and the local symptoms of heat 
and irritation in the mouth continued until just before the tooth had pierced the gum. 
After that time the discharge from the ear ceased, and the infant became perfectly well, 
the local irritation also having disappeared. 

Three or four days previous to being seen at the clinic the same symptoms re- 
turned. The infant was evidently suffering from irritation in its mouth. Sometimes 
the gums were hot and dry, and again there was a hypersecretion of saliva. It con- 
tinually put its finger to the gum of the lower jaw, sometimes almost locating it near 
the place where the first tooth was cut. The ear had begun to discharge again, and 
the infant showed signs of general discomfort by rubbing its nose and head continu- 
ally and at times crying out as though in pain. 

On examining the. gum it was found to be swollen, but there was no especially 
tender point. On examining the ears an old perforation of the membrana tympani 
was found in the right ear, which was discharging, while in the left ear there was a 
simple congestion. 

Such cases as this are often treated by lancing the gum, yet this procedure is not 
of the slightest use, and is, in fact, contraindicated, as it will only increase the already 
existing irritation of the mouth. The treatment should be the internal administration 
of bromide of potassium and appropriate local treatment for the ear. 

The other cases are so similar and are so commonly met with that 
I need not dwell upon them, but shall report one of the cases in which 
lancing of the gum is indicated. 

An infant, eight months old", and in good health, cut its first tooth when it was 
seven months old. At this time there were no nervous disturbances, the tooth coming 
through the gum without any reflex or local symptoms whatever. 

When the second tooth was pressing on the gum I was called to relieve the fol- 
lowing symptoms. The infant, who had been perfectly well, and who on examination 
showed no disease of any organ, was reported to have been feverish, restless, and 
crying out with pain for the previous twenty-four hours. It had refused to nurse, 
had not slept for thirty-six hours, had vomited a number of times, and was found to 
have a temperature of 40° C. (104° F.). It twitched from time to time, and appar- 
ently was in danger of having general convulsions. On examining the mouth one of 
the lower middle incisors was found to be entirely through the gum. The gum next 
to this incisor was greatly swollen, tense, cartilaginous in feeling, hot, and tender, so 
that whenever it was touched the infant screamed with pain. I then lanced the gum. 
The expression of pain, which had been marked on the infant's face, disappeared im- 
mediately, and was replaced by an expression of tranquillity, and it was evident that 
the severe pain had been relieved instantaneously. The infant went to sleep at once, 
and slept two hours. When it awoke its temperature was normal, it took the breast 
with great eagerness, and from that time it had no more trouble in its mouth. All the 
rest of its teeth were cut without any abnormal symptoms. 

The following case illustrates to a still greater extent the necessity of 
lancing the gums in certain cases. 

An infant began to have irritation from its teeth when it was five months old. At 
this time it woke up in the night screaming, and continued to scream with pain for 
several hours, during which time its parents had to walk continually up and down 
the room with it. Various remedies were administered, but without the slightest 
relief, and finally, after two days of suffering, in which it refused to take its nourish- 



640 PEDIATRICS. 

merit, it lost in weight, and seemed very ill. An incision was made over the hot and 
swollen gum, with immediate relief. 

The same symptoms occurred when the next tooth appeared beneath the surface 
of the gum, but were relieved, after waiting for a few hours, by lancing. Of the re- 
maining eighteen teeth, six or eight gave rise to similar symptoms, but in every instance 
immediate relief was afforded by the lancing of the gum. 

DISEASES OF THE NOSE. 

The nose is the normal passage for the entrance of air to the lungs, 
and it is principally here that the air is modified before entering them. 
In normal respiration the mucous membrane of the nasal cavities, on 
account of the peculiar shape of the turbinated bones, presents a large 
surface to the inspired air, and is therefore admirably adapted to filter it 
of particles of dust and micro-organisms. The air is also warmed and 
changed so that before it reaches the larynx it is saturated with moisture 
and heated to a temperature of 35° C. (95° F.). This modification of- 
the air is especially important in the new-born, since the lung has so 
lately been brought into use and is in such a comparatively undeveloped 
condition that it cannot withstand unchanged air, to which it adapts itself 
better later in life. The passage through which the air passes in going to 
and through the naso-pharynx is extremely narrow in young infants, and 
can easily become occluded. There are not .many diseases which occur 
in the nose in infants and young children, and those which we do find 
are serious chiefly by being the cause of occlusion. In case of mouth- 
breathing due to nasal occlusion in an infant, the air which has not been 
modified by passing through the nose and naso-pharynx may have a detri- 
mental influence on the lung and general circulation, thus striking a serious 
blow at the infant's vitality. In later childhood, although the occlusion 
which arises in the nares may not be so serious as regards the life of the 
patient, yet the results of such a condition will be represented by retarded 
development of the child and interference with the function of hearing, 
with resulting mental dulness. 

RHINITIS. 

The most common pathological condition which occurs in the nose in 
infancy and childhood is some form of rhinitis. This may be acute or 
chronic, catarrhal or purulent, hypertrophic or atrophic. New growths 
are rare. Of these the more common is myxoma or simple mucous 
polypus. 

Acute Rhinitis. — Acute rhinitis (acute coryza) is an inflammation 
of the mucous membrane of the nasal cavities. 

Etiology. — The cause of the disease in most cases is apparently undue 
exposure to cold, though it may be proved eventually that this exposure 
merely prepares the way for the attack of some micro-organism. The 
frequency with which a cold in the head follows a similar condition in an 
attendant or a companion, suggests strongly a direct infection. This con- 



DISEASES OF THE NOSE. 641 

dition may in almost all cases be considered as part of a disease which 
affects the mucous membrane of the naso-pharynx as well as of the nares. 

Symptoms. — The symptoms are a sense of fulness, burning, and dryness 
in the nostrils, succeeded in a few hours by a serous discharge, which 
later becomes muco-purulent. There is usually a slight rise of tempera- 
ture, and, although the general symptoms are often slight, there is com- 
monly a very evident sense of discomfort, with loss of appetite and general 
malaise. In some cases, by direct extension of the inflammation through 
the Eustachian tube, an otitis media may be caused. The entrance of air 
into the naso-pharynx is blocked by the swelling of the erectile tissues 
covering the turbinate bones, and almost complete occlusion takes place. 
The patient is then forced to breathe with the mouth open, and a result- 
ing condition of dryness of the mucous membrane of the mouth and 
throat and a choking sensation arising from it follow. The natural ten- 
dency of an infant or young child is to keep the mouth shut, so that often 
when the nose is occluded it breathes with great difficulty when asleep, 
and its face becomes congested and even cyanotic. On forcing the mouth 
open the symptoms of congestion and cyanosis disappear, and the child 
begins to snore, and breathes with comparative comfort so long as its 
mouth remains open, until the dryness of the throat wakes it up. 

Prognosis. — The prognosis in these cases of acute rhinitis is usually 
good. The disease runs its course in a variable period of from three days 
to a week, and, unless the child is subjected to fresh exposure, it recovers 
entirely. The prognosis, however, varies in accordance with the age of 
the individual attacked. The danger that a young debilitated infant may 
die from exhaustion when the nares are occluded is considerable, and I 
have seen a puny, ill-cared-for infant die of a simple acute rhinitis with 
occlusion. Instances of this kind should warn us that active treatment 
is indicated. 

Treatment. — The treatment should be directed primarily to relieving 
the nasal occlusion. This is best accomplished by atomizing the nose. 
In most cases the oil atomizer containing oleum petrolatum album is 
sufficient to afford relief. In addition to the local treatment, the adminis- 
tration of stimulants is indicated when there is exhaustion. Care should 
be taken that the infant is taking a sufficient amount of nourishment. 
This is especially difficult to determine if it is nursing, as under these 
circumstances it will often hold the nipple in its mouth and apparently 
suck, while its breathing is so much disturbed by the nasal obstruction 
that it does not draw much milk from the breast. The various drugs 
which have been recommended for acute rhinitis have not in my hands 
proved to be of much use. I have occasionally found that a few drops 
of the tincture of euphrasia repeated three or four times at intervals of 
an hour will seemingly lessen the nasal secretion. 

An instance of this class is the case of an infant who had an attack of acute 
rhinitis when she was four months old. Although she was well nourished and fairly 

41 



642 PEDIATRICS. 

strong, yet the occlusion of the nares, which took place rapidly, produced serious 
symptoms. She was somewhat cyanotic, refused to take her food, which had to be 
forced down her throat, and was sleepless, while her strength failed rapidly. She was 
cared for by a trained nurse night and day, the oil spray was used at frequent intervals, 
and stimulants were given, with the inhalation of oxygen once every three or four 
hours. Under this treatment she improved slowly and recovered entirely. 

In older children the serious symptoms just described do not occur, 
as a rule, and the disease is not much more significant than the coryza 
of the adult. 

Purulent Rhinitis. — A rather rare form of rhinitis is at times met with, 
in which the discharge is essentially purulent. It is subacute or chronic 
in character, and is generally associated with unhealthy surroundings and 
some constitutional weakness. 

Etiology. — In these cases of purulent rhinitis a purulent discharge 
from the nose may be the result of an unsuspected foreign body in the 
nasal passages. This is especially likely to be the case if the discharge is 
from one side only. It frequently occurs in children, as they are very 
apt to push various bodies up their noses. If the foreign body happens 
to be a piece of thin paper or other soft material, it may not cause much 
nasal obstruction, and its presence may easily be overlooked even when a 
probe is carefully used in making the examination. This form of rhinitis 
is not accompanied by any especial enlargement of the turbinate bones, 
and narrowing of the nasal passages is not a prominent symptom. 

Symptoms. — The symptoms are chiefly a purulent discharge from the 
nostrils, and redness and excoriation produced by the acrid character of 
the discharge. 

Prognosis. — The prognosis of purulent rhinitis is good, except in ex- 
tremely debilitated children. . 

Treatment. — The treatment consists in cleanliness, especial attention 
being paid to cleansing the nares with alkaline solutions, and in attention 
to the general health. 

Hypertrophic Rhinitis. — This form of rhinitis is rare in infancy and 
childhood, and I shall therefore merely refer to it. Rhinitis is spoken of 
as hypertrophic when in addition to a chronic inflammation of the mucous 
and submucous tissues of the nose there is an actual hypertrophy of the 
mucous membrane, which results in occlusion of the nares and conse- 
quent interference with respiration and with the removal of the normal 
discharges from the nose. 

Etiology. — One of the most common causes of hypertrophic rhinitis 
is the occlusion of the posterior nares by adenoid growths, which inter- 
fere with the normal nasal secretions by retaining them in the nasal cavity 
and allowing them to decompose. A recurrent acute rhinitis may also be 
an etiological factor in hypertrophic rhinitis. 

Symptoms. — The most marked symptoms in hypertrophic rhinitis is 
the nasal obstruction, which usually alternates from one side of the nose 



DISEASES OF THE NOSE. 643 

to the other. As would naturally be expected from the lesions, the symp- 
toms are those of restlessness, especially at night, and various reflex 
phenomena connected with the throat and the larynx. Thus, there may 
be continued cough, and, when the Eustachian tubes are occluded, deaf- 
ness and a resulting hebetude. At times interference with speech results. 
There is not much nasal secretion in these cases, which aids us in the 
differential diagnosis from the other forms of rhinitis which have just 
been mentioned. 

Treatment. — The treatment of these cases when they are dependent 
upon growths in the naso-pharynx is the surgical removal of such 
growths. Mild astringent sprays should be used, and the oleum petrola- 
tum spray recommended in catarrhal rhinitis. As a rule, these cases 
should be placed in the hands of a specialist. 

Atrophic Rhinitis (ozcEna). — By atrophic rhinitis is meant a condi- 
tion of the nose characterized by atrophy of the mucous membrane and 
of the bony prominences within the nose, accompanied by what has been 
termed a dry catarrh, as a result of which the secretion of the nose forms 
crusts, which undergo decomposition and become fetid. It is also called 
ozaena. 

Etiology. — The disease is one which attacks older children rather 
than infants, and its etiology is obscure. The glandular function is im- 
paired, and the muco-purulent discharge becomes thick and firmly adhe- 
rent in the form of crusts to the sinuosities of the nose. This film of 
desiccated muco-pus in drying contracts the underlying turbinated tissues 
in such a way as to interfere with the circulation of the blood, a condition 
which limits glandular action still more and conduces to general atrophy. 

Symptoms. — The symptoms of atrophic rhinitis are the formation of 
crusts and the presence of fetor. 

Treatment. — Although the tissues which have actually been destroyed 
by the atrophic process cannot be restored by treatment, the patient can 
be entirely relieved of the crust formation and fetor by persistent and 
patient local washing and applications. The details of treatment differ 
according to the extent and character of the disease. Crusts may be 
removed by spraying or douching, great care being taken to prevent the 
washing fluid from entering the Eustachian tubes. If this is not sufficient 
to remove the crusts, the nasal cavities must be illuminated with a head- 
mirror, and the crusts carefully brushed off with a cotton-stick. The 
formation of dry, hard crusts is often prevented by frequent spraying 
with an oil. Local applications of different substances are of use in 
many cases, but these should, as a rule, be carried out under the direc- 
tion of a specialist in the treatment of diseases of the nose. 

MUCOUS POLYPUS. 

This is a pedunculated connective-tissue growth originating from the 
mucous membrane of the middle turbinate bone. It is rare in children, 



644 PEDIATRICS. 

It does not grow on a healthy mucous membrane, and is always preceded 
by some morbid condition of the nose. It is often multiple. 

The symptoms begin with a nasal discharge followed by nasal occlu- 
sion. The diagnosis is easily made by a mirror and a probe. The treat- 
ment is the removal of the growth. 

EPISTAXIS. 

During the period of early childhood epistaxis, or hemorrhage from 
the nose, is not uncommon. I have occasionally met with epistaxis in 
young infants, but in my experience it is rare in the early months of life. 
In older children recurrent epistaxis, especially if unilateral, points to the 
presence of an erosion or a varicose condition in the cartilaginous septum 
near the external opening of the nose. 

Unless the individual happens to be affected by haemophilia, epistaxis 
is not especially dangerous, and usually its occurrence ceases as the child 
grows older. 

Treatment. — The application of pressure on the side of the base of 
the nose and the use of ice are usually sufficient to stop the hemorrhage. 
If the epistaxis is due to the varicose condition just spoken of, it can be 
readily controlled temporarily by a plug of cotton pressed upon the bleed- 
ing part. For a permanent cure, cauterizing the bleeding part may be 
necessary. 

DISEASES OF THE EAR. 

It is very important to bear in mind, in examining infants and children, 
the common occurrence of some morbid process in the ear. In many 
cases in which the more pronounced aural symptoms are not evident, 
symptoms which appear obscure, but really are due to some latent dis- 
turbance in the neighborhood of the ear, reflex or otherwise, are readily 
explained when in addition to the presence of some other disease the 
unusual symptoms are found to arise from the aural complication. The 
question of diseases of the ear in infancy and childhood has not received 
from the general practitioner, nor, indeed, from those who devote them- 
selves especially to children, the attention that it deserves. Even leaving 
out of consideration the cases of disease of the middle ear incident to 
the exanthemata, serious implications of the ear from other causes are not 
uncommon during the first year of life, and we should especially watch 
for an aural complication in pneumonia. 

Von Troltsch found on examining forty-seven petrous bones taken 
from twenty-four unselected children that the middle ear was normal in 
only eighteen. The other twenty-nine ears showed in varying degrees 
the appearance of a purulent and sometimes, though rarely, of a mucous 
catarrh. Of the fifteen children with exudation in the middle ear, the 
youngest was three days and the oldest 'one year old ; five were in their 
first month, two each in their second and fourth, three in their third, and 
one each in their seventh, eighth, and twelfth months. 



DISEASES OF THE XASO-PHARYXX. 645 

In every five examinations of the ears of new-born children Schwartze 
found the tympanum filled with pus in two. 

Wreden found in eighty ears of children a normal middle ear in only 
fourteen ; purulent catarrh existed in thirty-six, and simple mucous catarrh 
in thirty ; the youngest child had lived twelve hours, the oldest fourteen 
months. The majority of these cases were, however, from three to 
fourteen days old. 

Edward Hoffman examined twenty-four petrous bones in infants vary- 
ing in age from thirty-two hours to four weeks, and found the tympanum 
filled with pus in seven cases. 

Of two hundred and thirty carefully examined cases under seven 
months of age Kutcharianz found the tympanic mucous membrane normal 
in thirty only. In fifty it showed either slight or intense catarrhal inflam- 
mation, and in one hundred and fifty the tympana were filled with pus. 

These statistics, quoted from Von Troltsch, serve to emphasize the 
statements of that author that even from the beginning of extra-uterine 
life "there is an unusually strong disposition to disease of the middle 
ear, owing on the one hand to the double influence of the peculiar 
morphological relations of the ear and the pharynx, and on the other 
hand to the diseases and conditions of life to which the child is frequently 
exposed." 

These pathological and clinical observations emphasize the fact that 
the ear in children is a very frequent source of infection by a number of 
pathogenic organisms, such as the pneumococcus and streptococcus, and 
that this infection, although frequently primary, is usually secondary to 
infection elsewhere, as from the cerebral meninges and especially from 
the naso-pharynx. 

We should therefore consider carefully the ear in all cases in which 
the symptoms are obscure, as well as in those diseases in which it is well 
known that aural complications are liable to arise. 

DISEASES OF THE NASO-PHARYNX. 

Although the cavity of the naso-pharynx is small and apparently in- 
significant, yet it plays a very important part in a number of the diseases 
to which children are susceptible. The condition which makes this por- 
tion of the respiratory tract especially important is the presence of the 
pharyngeal tonsil which lines its cavity. 

HYPERTROPHY OF THE PHARYNGEAL. TONSIL (Adenoid 

Growths ). 

The glandular or lymph-tissue which lines the vault and posterior 

Avail of the naso-pharynx is very similar to that which composes the 

faucial tonsils, and is called the pharyngeal, third, or Luschka's tonsil. 

Under certain circumstances this tissue becomes hypertrophied, and gives 

rise to the condition which is usually designated as adenoid growths. 



646 PEDIATRICS. 

Etiology. — The pharyngeal tonsils, like the faucial tonsils, are normal 
structures, and become pathological only when they are hypertrophied 
or diseased. Careful examination will reveal the presence of hypertrophy 
in the majority of children, but in normal cases it is small and produces 
no symptoms. Although hypertrophy of the pharyngeal tonsil may occur 
in infancy, it is uncommon before the second or third year. The disease is 
essentially one of childhood, as it very seldom develops after puberty. 
Acute inflammatory conditions or some obstruction in the nose are prob- 
ably the inciting causes of the hypertrophy. 

Pathology. — The pathological condition which is found in the lymph- 
tissues of the naso-pharynx is an hypertrophy which is very similar to 
the hypertrophic condition of the faucial tonsils, except that the latter 
contains a greater amount of connective fibrous tissue. The hypertrophy 
may be of greater or less extent, sometimes not being sufficient to cause 
any especial occlusion and at other times completely occluding the poste- 
rior nares. 

Symptoms. — The most prominent symptom noticed in children who 
have this disease is that they breathe with their mouths open at night and 
snore. As the nares become more occluded the child begins to breathe 
through its mouth also when it is awake. The interference with the 
proper passage of the air to the larynx and lung results in a chronic form 
of pharyngitis and laryngitis, while the blocking of the nasal end of the 
Eustachian tubes may result in a chronic catarrhal condition of the middle 
ear. Any or all of these symptoms may arise in an individual case 
according to the amount or position of the obstruction. The child's ex- 
pression changes, and is almost characteristic when the disease is fully 
developed. It holds its mouth open, and the lower jaw appears to drop, 
giving it a stupid look. If this condition continues after the seventh or 
eighth year, the bridge of the nose is apt to be prominent and its sides to 
look pinched ; the palate may be markedly arched, and the upper jaw 
narrowed laterally so as to crowd the teeth. The faucial tonsils may or 
may not be enlarged, but are usually so. Another symptom is an in- 
creased liability to attacks of acute rhinitis, and a tendency for these 
attacks to become subacute or chronic. 

Lack of development of the chest with flattening of the front of the 
thorax may be caused, not, as was formerly supposed, by the enlargement 
of the faucial tonsils, but by the occlusion caused by the hypertrophy of 
the pharyngeal tonsil. This hypertrophy with its resulting nasal occlusion 
may also be the cause of pharyngitis, laryngitis, and perhaps of bronchial 
catarrh or asthma, which can be cured only by the removal of the primary 
cause, the pharyngeal tonsil. 

Diagnosis. — The diagnosis of hypertrophy of the pharyngeal tonsil is 
not difficult in a marked case or if it is possible to examine the child's 
naso-pharynx. In young infants the posterior nasal space is so minute 
that it is almost impossible to reach it. The diagnosis can often be made 



DISEASES OF THE NASO-PHARYNX. 647 

simply by the appearance of the child, as there is no other disease which 
especially simulates this condition. A definite diagnosis, however, can be 
made only after the hypertrophied tonsil has actually been seen or felt. 

The importance of learning to detect by means of the finger the pres- 
ence of an enlarged pharyngeal tonsil is great. If an examination with the 
posterior rhinoscopic mirror can be made the exact extent of the hyper- 
trophy can be seen, and the child spared the discomfort of a digital exami- 
nation, but the examination with the mirror in the throat is usually so 
difficult in young children that the direct detection by means of the finger 
is often the best method. The child should have a blanket pinned 
around it tightly, so as to keep it from moving its arms. It should be 
held firmly sitting in the nurse's lap. The child's head is then held 
with one arm, pressing the cheek between the back teeth with the fore- 
finger, then passing the forefinger of the other hand gently, firmly, and 
quickly over the base of the tongue and behind the soft palate until it 
reaches the posterior wall of the pharynx. By quickly turning the finger 
upward, it is easy to feel whether the cavity of the naso-pharynx is 
clear or whether it is more or less filled by a soft, spongy mass, the hyper- 
trophied pharyngeal tonsil There is usually a little blood on the finger 
when it is withdrawn, as the growth is friable and bleeds easily. This 
examination is not, as a rule, very painful to the child, but is in many 
cases very disagreeable and alarming to it. When the finger is once in 
the mouth, it is not wise to take it out again until the examination is com- 
pleted, as the child can rarely be induced to allow a second attempt to 
be made. In passing the finger over the base of the tongue it is necessary 
to be careful to get the finger behind the soft palate, and not to push it 
upward and backward, for in this case the soft tissues of the palate may 
feel like an adenoid growth. The child can be prevented from biting the 
finger by simply keeping the cheek pressed between the teeth as has just 
been described. 

Fig. 139, page 648, represents the typical picture of an adenoid growth in a girl 
ten years old. She held her mouth open and evidently had complete occlusion of the 
posterior nares, the anterior nares on examination being found entirely free. The 
pinched look of the face on either side of the nose and the prominence of the bridge 
of the nose are to be noticed. The child was dull, the dulness having increased as 
the other symptoms of the adenoid growth developed, and her face had a stupid ex- 
pression. On examining the child's mouth the hard palate was found to be very much 
arched, the tonsils were enlarged, and the soft palate was slightly pushed forward, 
the pharynx being narrower than normal. 

After removal of the adenoid growth and faucial tonsils she found no difficulty in 
keeping the mouth closed, not only while awake, but also at night, and slept much 
more quietly than before. Her general health improved, and the development of her 
face during the remainder of its growth was normal. 

Prognosis. — The prognosis of cases of hypertrophy of the pharyngeal 
tonsil varies greatly, for there are all forms and degrees of the affection. 



648 



PEDIATRICS. 



In some cases the swelling of the lymph-tissues occurs only at intervals 
when the child has been subjected to exposure in inclement weather; 
it will then show itself simply by occlusion of the nares, with resulting 
discomfort, lasting for some weeks, but disappearing eventually as the 
weather becomes milder or if the child is taken to a different climate. The 
naso-pharynx has an important function besides being a passage-way for 
the air. It lubricates the pharynx, and by the action of its muscles opens 
the Eustachian tubes during the acts of swallowing and yawning, thus 
ventilating the ear. The prognosis, therefore, must vary according to the 
degree in which any of these functions are interfered with. When infants, 



Fig. 139. 




Hypertrophy of pharyngeal tonsil (adenoid growths). Female, 10 years old. 



before they have learned to articulate, become deaf they may gradually 
lose the power of speech, and from being deaf they may fall into a con- 
dition of hebetude which sometimes closely simulates idiocy, though it is 
not true idiocy, for the mental condition quickly changes when the cause 
of the disturbance has been removed. Unless irreparable injury has been 
done to the ear or to the general development, the prognosis is very favor- 
able, provided the proper treatment is carried out. 

Treatment. — The best treatment of these cases is to remove the 
adenoid growth at once. The operation in the hands of a skilful surgeon 
is not dangerous, and should be unhesitatingly advised. There are a 
number of methods which have been employed in operating on these 
cases. The child should be etherized, or, as is preferred by some opera- 
tors, chloroform may be employed. Most operators prefer to have the 
child held sitting in the lap of an attendant, others to have it lying down 
with its head bent backward. Dr. French, of Brooklyn, uses an especial 
chair adapted by him for operating in the upright position. There is less 
liability to extreme hemorrhage and to infection of the middle ear 



DISEASES OF THE PHARYNX. 649 

through the Eustachian tube in the upright position, and the danger of 
inspiring the blood, which has been given as a reason for operating in 
the prone position, is now well known to be visionary. The instru- 
ment which is commonly used is the Gottstein curette, which acts on 
the principle of a clraw-knife, held in a stirrup-shaped frame ; or a pair 
of post-nasal forceps held in the right hand is introduced, closed, into the 
naso-pharyngeal cavity. The blades are then opened, and pieces of the 
mass are grasped one after the other and pulled off gently : under no 
circumstances is force to be exerted. With proper care and assistance 
there is no danger to the child, and often in a few minutes a morbid con- 
dition which has existed for years may be practically cured. There are, 
of course, many details in this operation which must be thoroughly un- 
derstood in order that it should be successful. They need, however, 
scarcely be mentioned here, as the operation should be performed only 
by one whose work has especially fitted him for it. 

These growths when not extensive are sometimes removed even 
without ether with the curette or the finger-nail. 

The following case illustrates the benefit of operative treatment for the 
removal of the pharyngeal tonsil when hypertrophied. 

When the child was first seen at two years of age he had a very bright expression, 
and spoke well ; he showed nothing abnormal in connection with the shape of his nose 
or face. He heard well, slept with his mouth shut, and had a free passage of air through 
a perfectly normal nose and naso-pharynx. When he was three and a half years old, 
however, it was noticed that he snored at night, breathed with his mouth open, and 
was subject to continual attacks of rhinitis and naso-pharyngeal occlusion. Following 
these attacks his hearing became affected, and, while in his second year he had been 
bright and always ready to play with his parents, he became dull, and did not care to 
play with others, but would sit for hours playing by himself with his toys. 

A digital examination showed a mass of considerable size blocking the posterior 
nares. On the removal of this mass, which proved to be an hypertrophied pharyngeal 
tonsil, rapid improvement took place in his general condition, the dulness and hebe- 
tude disappeared, and he returned to the normal condition which he represented in 
his second year. 

There are other growths which occur in the naso-pharynx, such as 
sarcomata. They are, however, too rare to need especial description. 

DISEASES OF THE PHARYNX. 

Diseases of the pharynx in children are especially those affecting the 
tonsils, the uvula, the soft palate, and the posterior wall of the pharynx. 

TONSILLITIS. 

By tonsillitis is meant an inflammation of the tissues of the faucial 
tonsils. This inflammation may be acute or chronic. 

Acute Tonsillitis. — Acute tonsillitis {acute follicular tonsillitis, acute 
cryptic tonsillitis) is characterized by an acute swelling and redness of the 



650 PEDIATRICS. 

glands, and an exudation from the crypts. It is generally bilateral, but 
one tonsil may be affected before the other. The disease is not limited 
to the faucial tonsils, but commonly involves neighboring glandular struc- 
tures, such as the pharyngeal and lingual tonsils. 

Etiology. — The cause of this form of tonsillitis is undoubtedly infec- 
tion by some pathogenic germ. It is probable that more than one form 
of germ is capable of causing it. Many of the pathogenic germs which 
infest the mouth or the throat may be found in the crypts in this disease, 
but the especial germ by which we can characterize the disease has not 
yet been determined. 

Symptoms. — As a rule, the disease is characterized by an acute onset, 
with a heightened temperature, 39.4° to 40° C. (103° to 104° F.), loss 
of appetite, and general malaise. I have often noticed, however, that the 
symptoms of a marked follicular tonsillitis are not so acute and do not so 
definitely point to the throat in young children as they commonly do in 
older children and in adults. In fact, in many cases, unless the throat is 
actually inspected, it would seem as though it were not a local affection 
of the throat, but some general disease affecting other parts of the system. 
We should be especially careful, therefore, not to have our attention di- 
verted from the throat, but under all circumstances, where these symp- 
toms arise in young children, even though they apparently swallow 
without discomfort, the throat should be examined before deciding 
whether or not some other disease is developing. 

On examining the throat the tonsils are seen to be enlarged, red- 
dened, and in the early hours of the disease to show a little swelling 
of the orifices of the crypts, as though a secretion within them was about 
to burst the overlying mucous membrane and appear on the free surface. 
Later this actually occurs, and the tonsils are seen to be studded with 
white or grayish-white spots. These do not appear on the soft palate or 
uvula, though they may appear on the pharyngeal tonsil, the base of the 
tongue, and the posterior pharyngeal walls. The mucous membrane of 
the pillars of the palate, of the uvula, and of the soft palate are usually 
reddened, and there is very apt to be a decided reddening and even 
swelling of the mucous membrane and follicles of the pharynx. As the 
disease progresses these spots may coalesce and, adhering to the surface 
of the tonsil, form a pseudo-membrane which is often impossible, without 
a bacteriological examination, to distinguish from diphtheria. As there 
is a direct connection between the tonsils and the cervical glands, the latter 
are liable to be involved, though any great swelling of the cervical glands 
in connection with acute tonsillitis is uncommon. 

The disease is self-limited, and runs its course in two or three days or 
a week, at the end of which time the general symptoms subside, the 
appetite returns, the temperature becomes normal, and the child, although 
it is left somewhat weakened by the disease, seems as well as ever. The 
tonsils themselves, however, may not for some time regain their original 



DISEASES OF THE PHARYNX. 651 

size, and the exudation often remains in the crypts and may cause a 
chronic irritation with a tendency to recurrence. 

Diagnosis. — The differential diagnosis of follicular tonsillitis is to be 
made from the various forms of stomatitis, which have already been 
sufficiently described, and from diphtheria. It is now very generally 
known that it is impossible absolutely to exclude diphtheria by the morbid 
appearances seen on the tonsils. In the great majority of instances, how- 
ever, when the attack is acute, when the cervical glands are not especially 
involved, when the white spots on the tonsils are clearly located in the 
orifices of the crypts, and when there is no appearance of a membrane 
on the soft palate or pharyngeal wall, we can make a provisional clinical 
diagnosis of follicular tonsillitis with considerable confidence, but never 
with certainty without a bacteriological examination. 

Prognosis. — The prognosis of follicular tonsillitis is in almost every 
case favorable, and is rendered unfavorable only by the complication of 
a peritonsillar abscess, but it should be remembered that in an inflamed 
tonsil pathogenic organisms, such as those of diphtheria, are more apt to 
develop than when there is no inflammation. 

Treatment. — The treatment of acute tonsillitis, according to my ex- 
perience, should be entirely symptomatic. It is a self-limited disease, and 
in a vast majority of cases is not benefited by the administration of any 
drug internally or by local applications. In order to avoid the invasion 
of the various pathogenic germs during the progress of the tonsillitis I 
am in the habit of having the throat kept thoroughly clean with mild 
solutions of chlorate of potassium or borate of sodium. In young chil- 
dren, as a rule, I make no local application beyond allowing them to 
swallow cold solutions of chlorate of potassium in the strength which I 
have already advised (page 624). Small doses of quinine according to the 
age of the child are indicated when there is much exhaustion or malaise 
following the attack. 

The local application of a cleansing spray, and the administration of 
ice if desired to relieve the discomfort, constitute all that is necessary for 
the treatment of most cases. It is best not to disturb the mucous mem- 
brane with applications on swabs or brushes. 

The following case represents a follicular tonsillitis : 

A child (Plate XL. facing page 620, Follicular Tonsillitis), four years old, had an 
attack of follicular tonsillitis. 

She was taken sick two days before entering the hospital, with a heightened tem- 
perature of about 39.4° C. (103° F.), loss of appetite, and general malaise. She did 
not complain of her throat, and swallowed without difficulty. Nothing abnormal was 
found in any of the other organs, but on inspecting the throat the tonsils were seen to 
be enlarged and much reddened, and one or two of the orifices of the crypts were 
somewhat raised above the general surface of the tonsil. On the following day a 
number of white spots of different sizes appeared on both tonsils. On the clay 
of entrance the redness was mostly confined to the tonsils, and affected the uvula and 
palate very little. On the inner surface of both tonsils the exudation had coalesced. 



652 PEDIATRICS. 

so that it had an appearance very much like that of a pseudo-membrane. It is not 
uncommon in follicular tonsillitis for this coalescence of the exudation to take 
place on the surface of the tonsil which points towards the median line of the throat. 
The other appearances of the tonsils were characteristic of follicular tonsillitis. On 
the upper left-hand corner of the left tonsil, close to the arch of the palate, was an 
enlarged cryptic orifice which had not quite broken down, and which appeared as a 
light red prominence on the general surface of the tonsils. The orifices had a like 
appearance in various parts of both tonsils. On the anterior surface of the left tonsil 
were two white spots, caused by the exudation from the crypts. In the upper part of 
the right tonsil were three smaller yellowish-white spots, and lower down on the 
tonsil a grayish-white rather large spot, all of them due to the same cause. There 
were no other lesions in the throat, and the cervical glands were not involved. 

Cultures made from this exudation did not show the presence of the Klebs- 
Loeffler bacillus. 

The other affections of the tonsils, such as occur in the course of the 
exanthemata and in diphtheria, constituting the pseudo-membranous 
form of the disease, can best be described in connection with the especial 
diseases in which they arise. 

Chronic Tonsillitis. — The terms chronic tonsillitis and hypertrophied 
or enlarged tonsils are commonly used to express the same condition, 
especially in children, in whom a chronic inflammation of the tonsils un- 
accompanied by enlargement seldom occurs. 

Although this hypertrophy of the faucial tonsils may exist without a 
corresponding affection of the pharyngeal tonsil, yet it is very apt to be 
associated with this latter condition. 

Pathology. — The enlargement is a true hypertrophy, sometimes 
accompanied by more or less inflammatory deposit. If the parenchym- 
atous or glandular tissues are especially affected we find a soft, more or 
less red and vascular tonsil, with large crypts, often containing much 
secretion. In the interstitial form the tonsil is hard and tough, the 
crypts less prominent or even very small, and the vascularity much 
diminished. These types are the two extremes, and are rare ; in most 
cases the enlargement is essentially one of hypertrophy. The tonsils 
may be only moderately enlarged, or their size may be so increased that 
they meet, touching each other in the median line. 

Symptoms. — The symptoms of hypertrophy of the faucial tonsils vary 
according to the degree of enlargement. Normally the tonsils can 
scarcely be seen on inspection of the throat. In examining a child for 
enlargement of the tonsils care must be taken that the pharynx is not 
contracted by gagging at the time the examination is made. The act of 
gagging, which is easily brought about in children by a careless use of the 
tongue-depressor, brings the tonsils towards the median line, thus giving 
tonsils of normal size the appearance of being large and obstructive. 
When only moderately enlarged they may produce no symptoms what- 
ever, or they may be irritated by various external influences and be the 
source of recurrent acute affections of the throat. When considerably 



DISEASES OF THE PHARYNX. 653 

enlarged they may still not produce any marked symptoms, provided that 
the passage of air through the naso-pharynx is unobstructed. They may, 
however, even when the pharyngeal tonsil is not enlarged, cause ob- 
struction in the naso-pharynx by pressure as they enlarge upward and 
backward. When this happens, the same interference with the breathing 
and development of the child takes place as when the obstruction is 
primarily in the naso-pharynx. These symptoms are the same as have 
already been described in speaking of hypertrophy of the pharyngeal 
tonsil, and therefore need not be mentioned in detail here. 

Occasionally difficulty in swallowing and thickness of speech may 
arise when only the faucial tonsils are enlarged. 

Prognosis. — The prognosis in cases of hypertrophy of the faucial 
tonsils depends upon these varied anatomical conditions just described. 
So long as the tonsils do not encroach on the naso-pharynx the prog- 
nosis, so far as injury to the child is concerned, is good. We should 
remember, however, that the enlargement of the tonsils is a fertile source 
of irritation which may prepare the way for serious disease produced by 
the various micro-organisms. The prognosis as to their disappearance is 
not especially good, as when once hypertrophied they seldom recover 
their normal size without active treatment, though they generally diminish 
slowly in size after puberty. 

Treatment. — Local applications for the reduction of hypertrophied 
tonsils are useless. Some success has been obtained by Gampert by what 
is called discission of the tonsils. Leland has strongly advocated this 
treatment in certain cases. The operation consists in making slits in the 
tonsil with a knife especially devised by him. 

The most thorough and certain way of curing the disease is, however, 
by excision. If the pharyngeal tonsil also is hypertrophied the child 
should have an anaesthetic, and the operation for adenoid vegetations and 
tonsils should be done at the same time. If the tonsils alone are en- 
larged, they may be excised with the tonsillotome without an anaesthetic, 
provided they are not adherent to the pillars of the fauces. After the 
operation the child should be made to gargle with a solution of borate of 
sodium for two or three days (Prescription 84), and should be given only 
milk for its food. 

Prescription 84. 
Metric. Apothecary. 

Gramma. 

R Sodii Borat 2,0 R Sodii Borat gv. xxx ; 

Glyeerinae 20 Glycerins? g v ; 

Aq. destil. 180 Aq. destil g vi. 

M. M. 

Sig. — Gargle for throat. 

The hypertrophied tonsils may have become adherent to the anterior 
or the posterior pillars of the fauces to such an extent that the guillotine 
either cannot be used, or not without danger of wounding these pillars. 



654 PEDIATRICS. 

In such cases it may be necessary to resort to dissection or to the gal- 
vano-cautery to remove the tonsillar tissue. 

PERITONSILLAR ABSCESS. 

Symptoms. — In some cases an inflammatory process resulting in sup- 
puration occurs in the cellular tissue around, above, or behind the tonsil, 
constituting an abscess which is called peritonsillar. It is rather rare in 
early childhood. The disease is usually preceded by a certain degree of 
simple tonsillitis, and when it develops the temperature rises, perhaps to 
40° or 40.5° C. (104° or 105° F.), and the child evidently suffers much 
pain, and has difficulty in swallowing or even in opening the mouth. 

On inspecting the throat in these cases a unilateral swelling is seen in 
the neighborhood of the tonsil pushing the soft palate forward, and the 
tonsil towards the median line. 

Prognosis. — The prognosis is in almost every case favorable, except 
in those which have been neglected or improperly treated. There is 
rarely extensive burrowing of the pus. 

Treatment. — The treatment is to locate the abscess by careful pal- 
pation and to open it under strict antiseptic precautions with a guarded 
bistoury. 

PHARYNGITIS. 

An inflammatory condition of the posterior wall of the pharynx is 
rather rare in infancy, but is not uncommon in children. It is usually 
coincident with an inflammatory condition of the naso-pharynx or 
of the tonsils, but in a certain number of cases it is so much more 
pronounced in the posterior wall than elsewhere that it can be de- 
scribed as a separate disease. The diseases of the posterior wall of 
the pharynx are either (1) a simple catarrhal condition of the mucous 
membrane or (2) an inflammatory process in which the follicles are 
especially affected. In addition to these conditions, pus may form be- 
hind the mucous membrane, producing a retropharyngeal abscess. The 
inflammatory lesions of the pharynx may be acute or chronic. 

The conditions which give rise to pharyngitis are the same various 
morbid processes that involve the parts in the neighborhood of the 
pharynx, such as the naso-pharynx and the tonsils. These causes have 
already been mentioned. There also seems to be a connection between 
certain irritations arising in the gastro-enteric tract and the pharynx. 
When this occurs it is usually the chronic form of pharyngitis which is 
met with, and the causal connection between these two distant parts of 
the economy is probably of a reflex nature. 

Acute Simple Pharyngitis. — The pathological condition which is 
found in the simple acute form of pharyngitis is an acute inflammation 
characterized by a slightly heightened temperature, a hyperaemic con- 
dition of the blood-vessels of the posterior wall of the pharynx, and a. 
certain amount of swelling and of serous exudation. 



DISEASES OF THE PHARYNX. 655 

Symptoms. — The symptoms are discomfort in swallowing, and at first 
a feeling of dryness in the throat, followed later by an exudation of viscid 
mucus. The child does not seem especially sick with this disease, and 
the length of the attack varies according to the influences which are 
causing it. 

Acute Follicular Pharyngitis. — Symptoms. — The acute follicular form 
of pharyngitis does not differ materially in its symptoms from the simple 
form, and in fact both forms are so frequently combined that a clinical 
distinction need scarcely be made between them. On examining the 
pharynx in this form of pharyngitis, in addition to the appearances which 
are seen in the simple form, the follicles will be found enlarged and 
raised above the surface of the mucous membrane. 

Treatment. — The treatment of both forms of pharyngitis is essentially 
local, and is, as a rule, by applications to the inflamed mucous membrane 
in the form of a spray, either directly or indirectly through the nose. 
The spray is essentially for the purpose of cleansing and thus soothing 
the inflamed mucous membrane, and should consist of mild alkaline 
solutions such as the following : 

Prescription 85. 
Metric. Apothecary. 



Gramma 

R Sodii chloridi 

Sodii bicarb., 

Sodii boratis aa 

Aquae rosae 30 



3 R Sodii chloridi gr. v 

Sodii bicarb., 

9 Sodii boratis aa gr. xv 

Aquae rosaa ^ i ; 



Aqua? 90|0 Aquae ^ iii. 

M. M. 

Sig. — Spray for pharyngitis. 

Chronic Pharyngitis. — The chronic form of pharyngitis is usually 
accompanied by an irritating cough, which is most pronounced at night 
and in the morning. The mistake should not be made of thinking that 
these children who are coughing continuously, often losing in weight and 
looking weak and anaemic, are necessarily affected with bronchitis. This 
series of symptoms is frequently looked upon as diagnostic of bronchitis, 
when it really arises from pharyngitis, and can be cured by treating the 
latter disease. 

Treatment. — The treatment of chronic pharyngitis is to remove any 
hypertrophic condition of the tonsils, tongue, or nose, to regulate care- 
fully the child's general nutrition, and to avoid undue exposure to in- 
clement weather or to air vitiated in any way, as by dust. Local applica- 
tions of a one per cent, solution of nitrate of silver, followed immediately 
by thorough cleansing with sterilized water, are sometimes indicated in 
the more intractable cases. 

Elongation of the Uvula. — Symptoms. — Accompanying pharyngitis, 
usually in its chronic form, an elongation of the uvula is at times met 
with in children. This condition may arise from a relaxed condition of 



656 PEDIATRICS. 

the muscles of the soft palate and of the uvula, or may consist simply of 
a redundancy of the mucous membrane at the tip of the uvula. The 
general irritated condition of the uvula and the tickling sensation pro- 
duced by its elongated tip touching the base of the tongue cause a harass- 
ing cough, which by its persistence weakens the child, gives rise to loss 
of appetite, and interferes with its nutrition. 

A papillomatous growth is sometimes found attached to the tip of the 
uvula or to its side, which causes the same symptoms as elongation of 
the uvula. The treatment is excision, after which it does not recur. 

Treatment. — Local applications of astringents, such as alum, are at 
times sufficient to restore the uvula to its normal condition, but the dis- 
ease can be cured quickly by excising the end of the uvula with blunt- 
pointed scissors. The amputation of the entire uvula is to be avoided, 
as it has been known to weaken the muscular action of the soft palate. 

RETROPHARYNGEAL ABSCESS. 

Retropharyngeal abscess is a disease which occurs usually during the 
first year of life and is very rare after this time. The disease may be 
secondary to injuries of the pharynx, to abscess in the neck, and to dis- 
ease of the cervical vertebrae, or it may be metastatic from septic pro- 
cesses such as occur in diphtheria. In a certain number of cases it is 
idiopathic so far as we know. 

Pathology. — The pathology of the disease consists in the formation 
of an abscess in the tissues of the posterior wall of the pharynx, and is 
more apt to be on one side of the pharynx than in the median line. 

Symptoms. — The symptoms, whether the disease is primary or second- 
ary, are very much the same. The first symptom is generally difficulty 
in swallowing, which may go on to entire inability to swallow. The infant 
is next noticed to breathe in a peculiar way. It holds its head back and 
its mouth open. The breathing may be described as snorting, and at 
times as almost stertorous, differing markedly from the whistling sound 
which is heard in obstruction of the larynx. On examining the throat 
the soft palate is seen to be pushed forward and to be somewhat anaemic. 
The posterior wall of the pharynx is bulging, usually unilaterally, is 
reddened, swollen, tense, and as the disease progresses is found to be 
fluctuating. In some cases the abscess burrows into the tissues of the 
neck and appears as a pear-shaped tumor behind the ear. I have met 
with two cases of this variety where the pus could be reached easily by 
an external incision. 

Diagnosis. — The diagnosis must be made chiefly from peritonsillar 
abscess. This is, as a rule, not difficult unless the latter condition has 
proceeded so far that the pus by burrowing has invaded the walls of the 
pharynx. It is usually not difficult to determine the situation of the 
abscess by passing the finger directly through the mouth to the posterior 
wall of the pharynx. If there is pus in the tissues of the pharynx a 



DISEASES OF THE PHARYNX. 657 

sense of fluctuation Avill be obtained. The position of the child kl cases 
of retropharyngeal abscess is also significant, and is not that which is 
assumed in peritonsillar abscess. It holds its head back, in order to allow 
a free passage for the air through the occluded pharynx into the larynx. 

The diagnosis must also be made from oedema of the glottis, but this 
is not, as a rule, difficult, for inspection shows that in the latter disease, 
bulging, redness, swelling, and fluctuation of the posterior wall of the 
pharynx are not present. The characteristic position of the head, also, 
is not seen in oedema of the larynx. A case of retropharyngeal abscess 
can often be diagnosticated by the snorting and labored character of the 
respiration. 

Prognosis. — The prognosis in the cases in which the abscess is second- 
ary varies according to the nature of the disease which causes it. Thus, 
it is an exceedingly dangerous complication in diphtheria, and is one of 
serious import in cervical spondylitis. In those cases of undetermined 
origin which are spoken of as idiopathic the prognosis is very good if the 
proper treatment is carried out at once. We must, however, consider the 
possibility of the abscess bursting suddenly and of the child suffocating by 
inspiration of pus into the larynx. This has been known to occur when 
the disease has been left untreated. 

Treatment. — In the idiopathic cases the abscess should be opened at 
once. The method which I have found satisfactory in the cases which 
have come under my observation is to have an assistant hold the infant 
sitting upright in the lap, with a blanket tightly pinned around it so as to 
prevent it from moving its arms. Another assistant should hold the head. 
The mouth should then be opened, a guarded bistoury should be intro- 
duced into the pharynx and the abscess punctured. As soon as the open- 
ing has been made the bistoury should be removed quickly, and the 
infant's head should be immediately thrown forward and downward, so 
that the pus will be discharged from its mouth and not inspired into the 
larynx or swallowed. It is usually necessary after the operation to intro- 
duce the finger into the pharynx and to press the walls of the abscess, so 
as to empty any pus which may continue to collect there and also to keep 
the opening free. With this treatment, unless some complication should 
arise, the disease is usually cured in about a week. 

Some operators prefer having the child placed in what is known as 
Rose's position, on its back with the head hanging over the end of the 
table. 

Fig. 140 represents a typical case of retropharyngeal abscess in an infant seven 
months old, showing the characteristic appearance produced by the obstruction in the 
pharynx. The head was held back and the mouth open : the eyes were somewhat 
rolled upward, but she was perfectly conscious. The face was slightly cyanotic. On 
depressing the lower jaw and tongue the soft palate was seen pressed forward, and the 
blood-vessels were found to be almost empty and very pale. On the left of the median 
line a swollen, congested, bulging condition of the mucous membrane was seen on 

42 



658 PEDIATRICS. 

throwing a strong light from the mirror on the posterior wall of the pharynx. On 
touching the most prominent point of the swelling with the finger a sense of fluctuation 
was obtained. 

The infant was said to have been sick for two weeks with a cold in its head. Three 
days before I saw it it began to breathe in a labored manner and to hold its head back 
rigidly and somewhat to the left. It also began to hold its mouth open. It was able to 
nurse only a few seconds at a time, when it would let go of the nipple and refuse to 
take it again. It had been growing very weak from lack of nourishment and from the 
exhaustion arising from the difficulty in breathing. 

Fig. 140. 




Retropharyngeal abscess. Male, 7 months old. 

An opening in the abscess was made, and a large amount of pus was evacuated. 
An hour later the child began to choke, and it seemed as though tracheotomy would 
have to be performed, but pressure with the finger on the walls of the abscess from 
time to time, surrounding the infant with an atmosphere containing steam, and free 
stimulation, proved eventually to be all that was necessary for its recovery. 

The next case was one of an infant thirteen months old, always strong and 
healthy, who had an attack of acute rhinitis for several days. The rhinitis apparently 
caused considerable swelling and occlusion of the nares, and the infant after four or five 
days began to hold its' mouth open when breathing and to have difficulty in swallow- 
ing. This difficulty in deglutition increased, and it was then noticed that her head 
was held back. On examining the throat a tense fluctuating swelling was detected in 
the posterior wall of the pharynx very nearly in the median line. This swelling was 
incised, a considerable amount of pus was evacuated, and the infant immediately began 
to breathe more easily and was able to swallow without difficulty. During the next 
twenty-four hours the abscess filled with pus a number of times, and the pus had to 
be emptied by pressure with the finger. The infant made a perfect recovery, and had 
no return of the disease. 

In an ordinary case, when the pus has come from the breaking down 
of glandular material in the posterior wall of the pharynx and already 
contains pyogenic bacteria, the dangers from reinfection from a wound in 
the mouth are not serious. But when the pus has come from a tubercular 
focus in the cervical vertebrae and contains no other organisms than the 
tubercle bacillus, and is, moreover, in direct communication with an active 
pathological process in the bone, the risks of a secondary septic infec- 
tion are considerable. It is, therefore, the practice of many surgeons, 
notwithstanding the difficulties of the operation, to attempt to reach the 
abscess by a careful dissection from the outside of the neck, as in this way 



DISEASES OF THE PHARYNX. 659 

it is far easier to keep the wound aseptic. If there is any sign of the abscess 
pointing externally, the external operation should always be preferred. 

In the following case the retropharyngeal abscess was secondary to 
cervical spondylitis. 

Fig. 141. 




Retropharyngeal abscess secondary to cervical spondylitis. 

This child was being treated for cervical spondylitis, when in addition to the drawing 
back of its head, as shown in Fig. 141, it began to have increased difficulty in swal- 
lowing and to breathe with its mouth open. 

On examining the pharynx a bulging, tense, fluctuating abscess of moderate size 
was detected. 



DIVISION X. 

DISEASES OF THE LARYNX, TRACHEA, SRONCHI, 
LUNGS, AND PLEURA. 



DISEASES OF THE LARYNX. 

The affections of the larynx which occur most commonly in infants 
and in young children are neuroses, new growths, lesions produced by 
foreign bodies, cedema, and laryngitis. 

LARYNGOSPASMUS. 

Laryngospasmus (laryngismus stridulus) is a neurosis which especially 
affects the larynx in infancy and childhood, and will be described under 
the name of laryngospasmus when speaking of reflex irritation of the 
larynx on page 944. 

There is a form of laryngospasmus known as congenital stridor, char- 
acterized by a croaking sound accompanying inspiration, sometimes by a 
crowing sound. There is no dyspnoea, cyanosis, or diminution in the 
power of the child to cry or to cough. Expiration is usually noiseless. 
The stridor is apt to increase in loudness during the first few months of 
life, but gradually disappears during the second year. Thomson and 
Turner have concluded from a careful anatomical study that the sound is 
due to a valvular action of the upper aperture of the larynx by which its 
lateral walls are drawn inward during inspiration. This is due, not to a 
congenital malformation, but to an incoordination and to spasmodic action 
of the muscles of respiration, which they call a choreiform, respiratory 
spasm, analagous to stammering, and differing from a laryngeal spasm. 

NEW GROWTHS. 
New growths in the larynx in infants and in children are rare. They 
may be congenital, but these are very uncommon. They may be malig- 
nant, such as epitheliomata and sarcomata, or benign, such as fibromata, 
myxomata, and papillomata. Those of the former class are so rare that 
they need here only be referred to. Of the latter class the fibromata and 
myxomata are too rare to be more than mentioned. The papillomata, 
on the other hand, although rare, are the most common laryngeal growths 
in early life. They may produce such serious results that it is important 

660 



DISEASES OF THE LARYNX. 661 

to recognize them at once. They may be congenital. Their cause is not 
known. Papilloma of the larynx in young children is usually multiple. 

The symptoms of this growth appear at about the first, second, or 
third year. The first symptom that is noticed is hoarseness. This hoarse- 
ness, instead of passing off in a few days, as is common when it arises 
from other affections of the larynx, continues and grows more marked. 
The next symptom is dyspnoea. This appears at intervals of a few 
months, or may not arise for some years after the first alteration of the 
voice. The dyspnoea first appears at night, when the child is asleep. 
In the daytime, when the child is awake and running about, it may 
breathe freely. As the papillomata increase in size, the dyspnoea appears 
in the daytime also, especially when the child makes any exertion. When 
it is awake and is quiet the breathing may not be noticeably affected, 
even after the growth has attained a large size. Cough may be present. 
Usually there is no pain nor difficulty in swallowing. When a child pre- 
sents these symptoms a careful laryngoscopic examination should be 
made at once, as in this way only can the diagnosis be verified. 

Prognosis. — The prognosis in these cases is bad unless the growths 
are removed. 

Treatment. — The best treatment of multiple papillomata is to remove 
the growths through the mouth. This is, however, a difficult operation. 
Without an anaesthetic it is hard to control the child, and many attempts 
may be required. With an anaesthetic, if the growth is sufficient to cause 
much obstruction there may be cessation of breathing during the opera- 
tion, requiring immediate tracheotomy. Many operators prefer to do a 
previous tracheotomy, especially as it may require more than one opera- 
tion to clear the larynx. Intubation has been recommended, but it is 
attended with the danger of breaking off some of the groAvth which may 
find its way into a bronchus. 

The difficulty of removal is in some cases so great that some of the 
most competent operators have preferred, if the case is not urgent, to 
postpone the operation until the child is older. The child during this 
time must be kept under strict supervision, but local applications are not 
indicated. These growths, even when completely removed, have a ten- 
dency to recur. 

FOREIGN BODIES. 

Foreign bodies rarely lodge in the larynx, but this accident occurs 
more commonly in children than in adults, as children are apt to put 
articles of every description into their mouths. 

The symptoms which indicate the presence of a foreign body in the 
larynx are a sudden attack of suffocation and a change in the sound of the 
voice in a child who has previously shown no signs of obstruction and no 
symptoms of laryngeal disease. 

The accident is one which is so serious that the child should be placed 
at once in the hands of a laryngologist. The larynx should be examined 



662 PEDIATRICS. 

with the laryngoscope, and the foreign body removed, if possible, with the 
forceps. Great care should be taken not to push the foreign body into 
the trachea, as tracheotomy would then be necessary. For the same 
reason it is inadvisable to introduce the finger blindly into the larynx, or 
to do anything which may cause a sudden inspiration. 

(EDEMA. 

(Edema of the larynx is not a common condition in early life. It may 
arise from a number of causes, and is secondary to some disease elsewhere 
or to some local irritation. It occurs as a rare complication in nephritis 
and in the acute exanthemata. It may arise from irritation produced by 
local lesions, such as ulcerations, from foreign bodies, from inhalations of 
hot vapors, from the swallowing of corrosive liquids, and also as the 
result of any acute inflammation, such as erysipelas. The diagnosis, as 
a rule, must be verified by a laryngoscopic examination. 

Treatment. — The treatment is that of the disease or local irritation 
which is causing the oedema. The local application of cold, and, if neces- 
sary, scarification of the oedematous tissue, are indicated. If the attack 
is pronounced and suffocation is imminent, we should be prepared to 
perform tracheotomy or intubation. 

LARYNGITIS. 

The most common inflammatory lesions of the larynx which occur in 
early life are (1) catarrhal laryngitis (false croup, croup) and (2) pseudo- 
membranous laryngitis (membranous croup). 

Acute Catarrhal Laryngitis [false croup). — The pathological con- 
dition which is present in the acute form of laryngitis is a redness or 
hyperemia of the laryngeal mucous membrane, accompanied by more or 
less swelling and serous exudation. The cause of acute catarrhal laryn- 
gitis is often a simple extension of a catarrhal condition of the nose and 
pharynx to the larynx. More rarely a catarrhal condition of the bronchi 
and trachea may extend upward and involve the larynx. At times the 
condition appears to be the result of atmospheric changes and undue 
exposure to dampness and cold. The lumen of the larynx in infancy 
and in early childhood is so small that even a moderate swelling of the 
laryngeal mucous membrane may produce sufficient stenosis to give rise 
to marked obstructive symptoms. 

Symptoms. — The symptoms of acute laryngitis are a heightened 
temperature, 38.3°, 38.8°, 39.4° C. (101°, 102°, 103° R), and even 
higher, hoarseness and cough. These symptoms, occurring in connec- 
tion with a preceding rhinitis or pharyngitis, or arising from a primary 
inflammation of the larynx, may continue for a number of days without 
any more serious manifestations, and if the child is kept in an equable 
temperature the attack may pass off within a week. In some cases, 



DISEASES OF THE LARYNX. 663 

however, another set of symptoms may appear after the primary mani- 
festations have lasted for a variable period. The child may be as well 
as usual in the morning. Towards the latter part of the day its voice 
becomes hoarse and there is a slight cough, but without any other symp- 
toms of special importance. After being restless for a time it suddenly 
awakes, and springs up in bed frightened, often clutching at its throat as 
if it had a sensation of suffocation. The cough, which during the day 
was hoarse and somewhat metallic, is now loud and rasping. The child 
has difficulty in breathing, amounting to orthopnoea, and its face is con- 
gested. These symptoms continue for a variable period ; usually they last 
for only one or two hours, but rarely may continue for many hours. In 
one very uncommon case which was under my care the attack lasted for 
three or four weeks, during which time it often seemed as though suffo- 
cation was imminent. There was in this case no evidence of any lesion 
beyond a catarrhal laryngitis, and recovery finally took place. These 
attacks are partly due to obstruction in the larynx from the swollen 
mucous membrane, the seat of the swelling in these cases being sub- 
glottic, but they are largely the result of a neurosis due to a highly sen- 
sitive condition of the mucous membrane. On the following day the 
hoarseness may continue, but the child seems bright and plays about as 
usual. It is very common for the attack to recur on the second night 
with greater severity, but in certain cases one attack terminates the dis- 
ease, and after a variable number of days, the voice becoming clearer 
each day and the temperature returning to normal, the child recovers. 
Children who have once had attacks of this kind are liable to have recur- 
rences until they grow older. 

Diagnosis. — The diagnosis of acute catarrhal laryngitis is to be made 
from foreign bodies in the larynx, traumata, and membranous laryngitis. 
The symptoms in the first two are not preceded by catarrhal symptoms 
elsewhere, which are almost always met with in catarrhal laryngitis. In 
a typical case of acute catarrhal laryngitis with suffocative symptoms the 
diagnosis is not difficult. The acute, sudden onset of the attack in the 
night, the loud, metallic cough, and the heightened temperature, are dis- 
tinct from the moderate temperature and the slow, progressive stenosis 
caused by the formation of a membrane in the larynx. 

Prognosis. — Acute laryngitis is a self-limited disease, and one in which 
the prognosis is almost invariably good. In children who are very weak 
and debilitated the interference with their respiration may prove to be 
serious, but these cases are rare and should be treated with stimulants 
until the disease has run its course. The symptoms of acute catarrhal 
laryngitis are so terrifying to the parents that the physician is often led to 
look upon the disease more seriously than is necessary. 

Treatment. — The treatment of acute catarrhal laryngitis is to keep the 
child in a room of an equable temperature of about 20° to 21° C. (68° 
to 70° F.) until its temperature has become normal and the hoarseness 



664 PEDIATRICS. 

has disappeared. I have also found that a few drops of wine of ipecac, 
given in the latter part of the afternoon and just as the child is going to 
sleep, are of benefit in preventing the spasmodic, obstructive symptoms 
which have just been described as occurring in the night. When the attack 
occurs in the night the symptoms of suffocation can be best relieved by a 
dose of from five to ten minims of wine of ipecac, or an amount suffi- 
cient to nauseate slightly. An emetic will sometimes cut short an attack 
of this nature, but in many cases is not necessary. An amount of ipecac 
sufficient to nauseate slightly, but not to cause the child to vomit, will 
often so relax the spasm of the larynx that the attack will soon be relieved. 
In many cases, however, even if vomiting has been produced, the attack 
continues, and other measures for relief are required. In addition to the 
ipecac, moderate doses of tinctura opii camphorata, 0.3 to 0.6 c.c. (5 to 
10 minims), may be given. An atmosphere of steam usually gives great 
relief to the spasm. Many accidents have occurred from the improper 
management of the steam and from giving such emetics as turpeth mineral. 
The necessity for operative measures rarely arises. 

Chronic Laryngitis. — A chronic form of laryngitis occurs in both 
infants and children. Syphilitic infants are at times affected by chronic 
laryngitis. It may also occur in tubercular disease, but is not common. 
When an acute laryngitis has occurred a number of times, or when an 
attack has been much prolonged by improper treatment, chronic laryngitis 
may result. In many of these cases the voice, on the slightest exposure 
to dampness, becomes hoarse, and this hoarseness, after a time, may be 
continuous. 

Treatment. — The treatment is to apply astringents to the pharynx, 
which is almost universally involved, and to regulate the climatic sur- 
roundings of the child. Local applications to the larynx in these cases 
are seldom necessary. 

Pseudo-Membranous Laryngitis. — A pseudo-membrane in the larynx 
may be caused by the inhalation of irritating vapors, or by the inspiration 
of corrosive liquids. These accidents are so readily recognized that there 
is no difficulty in determining the cause of the pseudo-membrane in these 
cases. Treatment for the relief of the stenosis should be instituted at 
once. This consists in the application of cold and such soothing inhala- 
tions as 3.75 c.c. (1 drachm) of compound tincture of benzoin in a quart 
of boiling water. The complicating oedema which is often present in 
these cases may require operative interference. 

The most common cause of pseudo-membranous laryngitis, and the 
one which probably in nearly all cases produces it, is some form of micro- 
organism. These micro-organisms may be of several varieties. Until it 
is proved not to be so, however, pseudo-membranous laryngitis must be 
looked upon clinically as infectious and due most commonly to the Klebs- 
Loeffler bacillus. There is no doubt but that a simple catarrhal inflam- 
mation localized in the larynx may be produced by the Klebs-Loeffler 



DISEASES OF THE TRACHEA, BRONCHI, AND LUNGS. QQ$ 

bacillus. The symptoms, diagnosis, and treatment of laryngeal diphtheria 
have been described on page 465. 

Some aid in the differential diagnosis of pseudo-membranous from 
acute catarrhal laryngitis can be obtained from the temperature, which in 
the latter is considerably raised, while in the former it is moderate and 
sometimes normal or subnormal. The slow course of a constitutional 
disease gradually causing obstruction is significant of this infectious form 
of laryngitis. 

DISEASES OF THE TRACHEA. 

Pathological conditions of the trachea not connected with those of the 
air-passage above or below it are uncommon. The lesions of the trachea 
may be primary or secondary. In the latter they are merely an extension 
of the disease from the larynx or the bronchi, and do not play an es- 
pecially significant part in the attack. The only primary disease of the 
trachea which is common in infancy and childhood is an acute inflamma- 
tion occurring in its mucous lining. When this inflammatory condition 
is present, it produces an irritating cough which can usually be excited by 
gentle pressure over the trachea, — about the only method by which we 
can locate the disturbance. 

The treatment is to protect the child from an atmosphere which is 
either too hot or too cold, from high winds, and from dust. Douching 
the front of the neck with cold water several times during the day is also 
desirable. Direct applications to the trachea are almost impossible in 
young children. 

DISEASES OF THE BRONCHI AND LUNGS. 

The diseases which affect the lungs in infancy and childhood differ 
somewhat from the same diseases occurring in later life, on account of the 
differences which exist in the anatomical conditions at birth and during 
the early years of life, especially the first five. The principle differences 
are that the bronchi occupy a relatively larger portion of the lung in the 
child than in the adult, that in the former the interstitial tissue is present 
in a larger amount, that the cavities of the air-vesicles are smaller, and 
that their walls are relatively thicker ; also that the epithelial cells lining 
the air-vesicles are very numerous. These cells in inflammation tend to 
rapid cell-division, which is one of the characteristics that mark the pneu- 
monia of childhood. These anatomical differences are of great signifi- 
cance when any part of the lung is diseased, and tend to make a con- 
gested lung of much more serious import in the young child than in the 
adult. Post-mortem examinations often show various lesions which 
during life were not represented by any definite symptoms, so that we 
cannot expect the clinical diagnosis to include entirely the pathological 
lesions. 



QQQ PEDIATRICS. 

ACUTE BRONCHITIS. 

By bronchitis we mean an inflammation of both the large and the small 
bronchi, with the exception of the ultimate divisions which lead directly 
into the alveoli, and which probably are never affected without involving 
the alveoli also. The disease may be acute or chronic. 

Etiology. — Bronchitis is often secondary to some other disease, or to 
a direct extension from an inflammatory condition of the upper air-pas- 
sages. In a number of cases, however, the group of symptoms by which 
we determine that bronchitis is present is so prominent from the very 
beginning of the attack that clinically we can describe a primary bron- 
chitis. 

The anatomical peculiarities of the mucous membrane lining the 
bronchial tubes — namely, the prominence of its capillaries and its com- 
paratively loose connection with the muscular walls — render the bronchial 
mucous membrane peculiarly susceptible to congestion. Exposure to 
sudden atmospheric changes, especially humidity, appears to be of great 
etiological importance in the production of bronchitis. Any impurity of 
an irritating nature in the inspired air may in certain individuals result in 
an attack of bronchitis. A catarrhal inflammation of the upper air-pas- 
sages is often followed by a similar inflammation of the bronchial mucous 
membrane. Bronchitis is of frequent occurrence in pertussis and measles. 
It is in children often a prominent symptom of typhoid fever, and is a 
frequent complication of pulmonary tuberculosis and epidemic influenza. 
There are also certain diseases of nutrition in which bronchitis frequently 
occurs. The most prominent of these is rhachitis, in which the com- 
plication of bronchitis is often of serious import. 

Pathology. — The pathological conditions which are present in acute 
catarrhal bronchitis are a congestion and swelling of the mucous mem- 
brane and an arrest of the functions of the mucous glands. Later, the 
mucous glands resume their functions with increased activity, the con- 
gestion diminishes, there is an increased desquamation of epithelium, an 
increased formation of the deeper epithelial cells, a moderate emigration 
of white blood-cells, and sometimes the red' blood-cells also escape through 
the vessels. The whole process is a superficial one, and does not produce 
any change in the walls of the bronchi beneath the mucous membrane, 
unless it has persisted for some time, when there may be a slight thick- 
ening of the walls. When the inflammation involves the smaller bronchi 
they may be occluded. The occlusion of the smaller bronchi may result 
in the collapse of the group of air-vesicles to which they lead, and thus 
areas of atelectasis will be produced, which may be further changed by 
inflammatory processes. The bronchial nodes are frequently enlarged, 
even in mild attacks of bronchitis. 

Fig. 142 represents the section of a child's lung, made by Northrup. 
It shows the exudative inflammation of the bronchi which occurs in acute 



DISEASES OF THE BRONCHI AND LUNGS. 



667 



bronchitis. The specimen shows hyperplasia of the lymph-nodes due to 
bronchitis. This condition is very commonly found in bronchitis, espe- 
cially when it occurs in debilitated children. There is desquamation of 
the epithelium lining- the bronchi, as well as a slight thickening of their 
walls. 

Symptoms. — The onset of acute bronchitis is usually mild, but I have, 
seen in a debilitated infant a simple, uncomplicated bronchitis begin Avith 
a convulsion. The symptoms are very variable in their intensity, and 
are usually more acute and definite in a previously healthy child than 
in debilitated children, in whom they are often subacute and of an in- 
sidious nature. In infants and young children the bronchitis is almost 
always preceded by a catarrhal condition of the upper air-passages. In 

Fig. 142. 




Br., bronchus; Art., artery: Lyrn. Gl., lymph-node. 

the mild cases there is an elevation of the temperature, 37.7° to 38.3° C. 
(100° to 101° F.), cough of greater or less severity, and a slight lessen- 
ing of the appetite. On physical examination the pulmonary resonance 
is found to be normal. A few sibilant and sonorous rales are heard with 
especial frequency in the area between the scapula and the vertebral 
column. Moist rales may also be heard. In severe cases the children 
suffer from more or less discomfort, produced probably by the thoracic 
pain, although in young children the locality of the pain cannot, as a 
rule, be determined. The cough is hard and dry, the respirations may 
be slighly raised, and the pulse accelerated. The children may appear 
quite ill for two or three days, and the temperature may rise as high as 
38.8° or 39.1° C. (102° or 102.5° F.) ; but when this latter point is 
reached the onset of a broncho-pneumonia should be carefully watched 



668 PEDIATRICS. 

for, especially if after from, twenty-four to forty-eight hours the tempera- 
ture does not fall to 37.7° or 38.3° C. (100° or 101° F.) 

After a few days the severity of the symptoms lessens, the cough be- 
comes looser, the rales gradually disappear, and under favorable condi- 
tions the symptoms subside entirely in a Aveek or ten days. There is 
seldom any expectoration in children under six or seven years. In the 
more severe cases the rales are more numerous than in the mild form of 
the disease, but are of the same character. In the course of some cases 
of bronchitis a temporary localized diminution or even absence of the 
respiratory sound may result from the occlusion of a bronchus. This is 
especially common in infants, and ordinarily is not accompanied by a 
change in the percussion-sound. This form of bronchitis is the one 
which affects the larger and the medium-sized bronchi. 

There is no characteristic temperature in bronchitis. As a rule, it is 
moderate, 37.2° to 38.3° C. (99° to 101° F.) but it varies greatly accord- 
ing to the individual and to the degree of nervous excitement. 

The blood shows nothing of diagnostic value (Cabot). Leucocytosis 
is not present in the usual forms of acute bronchitis, but only in the so- 
called capillary bronchitis (broncho-pneumonia), in which a leucocytosis 
is usually present. 

Diagnosis. — The diagnosis of the ordinary cases of acute bronchitis, 
in which only the large and medium-sized bronchi are affected, is not diffi- 
cult, the only disease for which it is likely to be mistaken being broncho- 
pneumonia. In this latter disease the greater severity of the symptoms 
and the higher temperature will usually show its presence, even though 
the physical signs may be only those described as occurring in bronchitis. 
In the more severe forms of bronchitis it is sometimes exceedingly diffi- 
cult to make the differential diagnosis from broncho-pneumonia. If t 
however, the temperature, after three or four days, remains high, and 
rises to 39.1° or 39.4° C. (102.5° or 103° F.), with marked remissions 
and exacerbations, the diagnosis becomes doubtful, and in these cases we 
should strongly suspect that a broncho-pneumonia has arisen as a com- 
plication. We must, however, remember that in certain cases of broncho- 
pneumonia the temperature may be as moderate as in acute bronchitis, 
and we must therefore rely on a combination of symptoms rather than 
on any one symptom or sign. An important point in the differential 
diagnosis between bronchitis and broncho- pneumonia is that the physical 
signs in the former are much more frequently found in all parts of the 
thorax, while in the latter circumscribed groups of rales are often de- 
tected in different parts of the lungs. The rales in themselves, however, 
are not distinctive, as the rales in broncho-pneumonia are mostly those 
of the accompanying bronchitis. Although the physical signs of dulness 
and bronchial respiration are conclusive evidences that the case is not one 
of bronchitis alone, yet an absence of these signs does not justify us in 
excluding broncho-pneumonia. When the dyspnoea, general prostration. 



DISEASES OF THE BRONCHI AND LUNGS. 669 

and restlessness are slight and the temperature moderate, the case is 
likely to be one of bronchitis, while if these symptoms are marked, and 
are combined with cyanosis, dilatation of the alae nasi, and a higher tem- 
perature, at least a provisional diagnosis of broncho-pneumonia should be 
made. In some cases the differential diagnosis will also have to be made 
from the onset of a pleuritis or of a lobar pneumonia, but the moderate 
temperature and respirations, the normal percussion-sounds, and the 
diffuse bilateral rales in bronchitis usually make the diagnosis from these 
diseases quite evident. If the blood-count shows an absence of leuco- 
cytosis it favors the diagnosis of bronchitis. 

Prognosis. — The prognosis, when no complication arises and the child 
is previously healthy, is good. In debilitated children, and especially 
when rhachitis is present, even a mild form of bronchitis may prove to be 
serious, on account of the danger of a complicating broncho-pneumonia, 
and in these cases the prognosis is much more unfavorable. 

Treatment. — The treatment of acute bronchitis is essentially hygienic. 
The child should be confined to a warm, well-ventilated room which has 
a sunny exposure, and which is heated by an open fire to a temperature 
of about 20° to 21.1° C. (68° to 70° F.). A few minims of wine of 
ipecac should be given if the cough is unusually dry, and to this a few 
minims of tinctura opii camphorata may be added if the patient is very 
nervous. These remedies are all that will usually be needed in an attack 
of acute bronchitis. When a rhachitic child or one who is much debili- 
tated is attacked by the disease, especial care must be taken to support its 
strength by stimulants and food. 

Unusual Form of Acute Bronchitis. — Besides the acute bronchitis 
just described, I have met with a class of cases which are extremely rare, 
but which, apparently, are instances of an exacerbation of an ordinary 
bronchitis through the involvement of the smaller bronchi, not the terminal 
ones. I have seen only six or eight of these cases. These, from their 
clinical history, seem to have been cases of bronchitis rather than of 
broncho-pneumonia. I speak of them separately, as the symptoms differ 
somewhat from those of an ordinary bronchitis. This form of bron- 
chitis has no connection with that which was formerly erroneously called 
capillary bronchitis, but which is well known to be only an early stage of 
broncho-pneumonia. This form of bronchitis in my cases has commonly 
occurred in infants in the first two years of life, though I have met with 
it as late as the third year. The cause, so far as could be ascertained, 
was the same as in an ordinary bronchitis, a catarrhal condition of the 
upper air-passages usually preceding the attack. The onset of the disease 
was rapid, and the symptoms soon became very severe. The tempera- 
ture was, as a rule, moderately raised, 37.7° to 38.3° C, (100° to 101° 
F.). The cough was continuous, and dyspnoea, with more or less cy- 
anosis, rapidly developed. An examination showed normal resonance 
throughout the whole thorax, and fine moist rales. The respirations were 



670 PEDIATRICS. 

rapid, the pulse was accelerated, and all the symptoms were of a violent 
and suffocative nature. The infants were much distressed, and were un- 
willing to be laid down. After from twenty-four to forty-eight hours the 
symptoms grew less severe, the temperature became normal or was 
only slightly raised, and the fine moist rales were replaced by coarse 
moist rales and the sibilant and sonorous rales of an ordinary bronchitis 
of the larger and the medium-sized bronchi. 

Diagnosis. — This form of bronchitis is to be differentiated from broncho- 
pneumonia. The temperature, instead of remaining high and having the 
remissions of a broncho-pneumonia, soon falls so as to correspond to that 
of an ordinary bronchitis. The physical signs are those of bronchitis 
rather than of pneumonia, and the rapid recovery of the infant with the 
common symptoms of an ordinary bronchitis, rather than with the pro- 
longed and characteristic symptoms of a broncho-pneumonia, points 
towards an inflammation of the smaller bronchi. These cases may be 
complicated with broncho-pneumonia, as are the ordinary cases of 
bronchitis. 

Prognosis. — In the early hours and days of the disease, when the 
symptoms are at their height, and if the infant is weak and debilitated, 
the prognosis is bad. If, however, the first few days are passed in safety, 
recovery almost invariably takes place. 

Treatment. — The treatment of this class of cases is very important, as 
death from exhaustion is liable to occur at any moment. The extreme 
congestion of the blood-vessels of the smaller bronchi may in some cases 
occlude the air-spaces, and areas of atelectasis may result. The indi- 
cations for treatment are to oxygenate the blood, to support the strength 
until the disease has run its course, and to prevent the infant from falling 
into a comatose condition. The treatment, therefore, is the adminis- 
tration of oxygen, the use of stimulants, consisting of aromatic spirit of 
ammonia alternating with brandy, and change of the position of the in- 
fant from time to time. 

The following case illustrates this unusual form of bronchitis : 

An infant, three months old, had an attack of acute bronchitis, characterized by a 
paroxysmal, dry cough, slightly accelerated respirations and pulse, and a moderate tem- 
perature varying from 37.7° to 38.3° C. (100° to 101° F.). 

The percussion of the chest had been normal, and there had been some sonorous 
and sibilant rales, with a few coarse moist rales heard on both sides of the chest. 
After three or four days the infant was attacked with excessive dyspnoea and cyanosis. 
Its pulse rose from 120 to 180, its respirations from 30 to 70, and its temperature 
from 37.7° to 39.1° C. (100° to 102.5° F.). An examination of the chest showed 
normal resonance and fine moist rales throughout both lungs. It was very restless, 
refused to take its food, and evidently wished not to be laid down in its bed, but to be 
carried about. It was treated with alternate doses of aromatic spirit of ammonia and 
brandy every half-hour. 

After twenty-four hours the temperature fell to 38° C. (100.5° F.), the pulse to 
150, and the respirations to 44. The fine rales were replaced by the ordinary coarse 
rales of a bronchitis, and the infant rapidly recovered. 



DISEASES OF THE BRONCHI AND LUNGS. 671 

The symptoms and course of all these cases are very similar, so that I 
shall speak only of one other child, whom I saw in consultation. 

A male, seven months old. and previously healthy, for two days had a slight 
cough, with a few sonorous rales in the chest and a temperature varying from 36.6° to 
37.2° C. (98° to 99° F.). On the third day of the attack he was suddenly seized with 
increased cough, dyspnoea, cyanosis, respirations of 70. a pulse of 160, and a tempera- 
ture of 38.3° C. (101° F.). An examination of the chest showed normal resonance 
and fine moist rales throughout both lungs. The infant was treated with aromatic 
spirit of ammonia and brandy in alternate doses. On the following day the tempera- 
ture fell to 37° C. (98.6° F.), and the fine rales were replaced by coarse and sonorous 
rales. The bronchitis lasted for a few days, and the infant then recovered entirely. 

CHRONIC BRONCHITIS. 

Etiology. — Chronic bronchitis may result from a series of attacks of 
acute bronchitis, or from a number of other causes. Among these may 
be mentioned various affections of the lungs, such diseases connected 
with malnutrition as rhachitis, and prolonged attacks of pertussis. 

Pathology. — The pathological conditions occurring in chronic bron- 
chitis vary greatly in degree, and the lesions found at the post-mortem 
examination are often slight in comparison with the severity of the symp- 
toms during life. In most cases there is a considerable production of 
mucus, pus, and serum. In cases which have lasted for a long time, in 
addition to the inflammatory products affecting the walls of the bronchi 
there may be dilatation of one or more bronchi, and the muscular coat 
may be thickened or thinned. Emphysema may also result. 

Symptoms. — The symptoms of chronic bronchitis are very much the 
same as those of acute bronchitis, except that the temperature is not so 
apt to be heightened, while the general symptoms of malaise, anorexia, 
and loss of weight are more prominent. In severe and prolonged cases 
in which emphysema is present, the thorax may assume the position of 
full inspiration, the ribs being permanently raised and the antero-posterior 
diameter of the chest increased. The physical signs are the same as 
in acute bronchitis, so far as the rales are concerned. The resonance is 
usually normal except when the chronic process has produced emphy- 
sema, in which case there are areas of hyper-resonance often associated 
with a tympanitic tone. Occasionally atelectasis of considerable areas of 
the lungs may take place, with a resulting diminution of the respiratory 
sound. This occurrence may in some cases prove to be serious, but in 
others the accompanying symptoms are mild, and the alveoli may again 
return to their normal degree of inflation. 

There is one form of bronchitis which from its duration may be called 
chronic, and yet which from the very slight degree of constitutional symp- 
toms that accompany it corresponds rather to a subacute affection. In 
these cases, which usually occur in infancy and in early childhood, the 
child often appears quite well, but for long periods of weeks, or when- 



672 PEDIATRICS. 

ever it is exposed to a damp atmosphere, a loud wheezing will be heard 
in the chest. Auscultation will reveal the presence of sonorous rales 
everywhere, and in this variety, as well as in other forms of chronic 
bronchitis, a roughened sensation may sometimes be felt on palpation 
during respiration. 

Diagnosis. — The differential diagnosis is to be made from chronic 
affections of the lungs in which the thickening of the interstitial tissue 
has taken place with a resulting diminution of resonance, and from the 
condition in which the bronchi are dilated. In the latter case there are 
accompanying symptoms of a profuse exudation of purulent matter. 

Chronic bronchitis is also to be distinguished from reflex coughs of a 
nervous character, unaccompanied by any disease of the respiratory tract. 
Causes for such reflex coughs may be found in irritation of the pharynx 
and ear, from chronic gastric indigestion, from pulmonary congestion, 
from the disturbances in circulation due to cardiac disease, and, finally, 
from pressure upon the bronchi of enlarged mediastinal glands. 

Prognosis. — The prognosis of chronic bronchitis varies according to 
the cause. When it is secondary to disease of some other organ, it 
depends entirely upon the prognosis of that disease. In rhachitic chil- 
dren the prognosis is unfavorable, and in them a broncho-pneumonia is 
especially liable to develop, with a fatal issue. Cases of chronic bron- 
chitis are also liable to be invaded by the tubercle bacillus. In cases 
which are the result of acute bronchitis in individuals otherwise healthy, 
the prognosis is favorable, provided the proper treatment can be carried 
out. As emphysema in chronic bronchitis is rare in children in com- 
parison with adults, the chances for recovery in the former are corre- 
spondingly good. 

Treatment. — The treatment of chronic bronchitis is essentially climatic. 
The children should be kept in a warm dry climate for some months after 
the bronchitis has entirely disappeared. Especial care should be taken 
that the child is suitably protected by flannel undergarments. When 
other treatment is required, as a rule, tonics will prove of more benefit 
than the drugs which are usually administered for their direct effect upon 
the bronchial mucous membrane. 

FIBRINOUS BRONCHITIS. 

During the course of what may appear to be an ordinary bronchitis, 
in rare instances a fibrinous form of bronchitis has been met with. In 
this variety masses of fibrin in the bronchi form casts of various extent 
according to the number of the bronchi which are affected. Similar 
fibrinous casts of the bronchi may be found in cases of diphtheria of the 
larynx by direct extension to the bronchi, but do not represent fibrinous 
bronchitis. 

The disease may run a short course of days or weeks, but is usually 
chronic and may last for years. The paroxysms may also be periodic. 



DISEASES OF THE BRONCHI AND LUNGS. 673 

The diagnosis can be made only when portions of the casts have been 
expectorated. 

Treatment. — The treatment is chiefly by the inhalation of steam or of 
atomized lime-water, and by supporting the strength with proper nourish- 
ment and stimulants until the disease has run its course. 

BRONCHIAL ASTHMA. 

Bronchial asthma is an affection characterized by spasmodic attacks 
of dyspnoea. The disease is rare in infancy, but is not uncommon in 
childhood. The term asthma should not be applied to dyspnoea which 
is dependent upon diseases of the heart and kidneys. 

Etiology. — It is generally accepted that there is a strong neurotic 
element in bronchial asthma, and by many writers it is considered a 
neurosis. The most plausible explanation of the attacks is the theory 
that it is due to a spasm of the bronchial muscles. Temporary swelling 
of the bronchial mucous membrane and inflammation of the smaller 
bronchioles, the bronchiolitis exudativa of Curschmann, have also been 
advanced as possible causes. 

Heredity seems to be a factor in predisposing an individual to the dis- 
ease. The direct exciting causes are many ; sudden atmospheric changes, 
inhalation of irritants, odors, and emanations of various kinds, frights and 
emotions, reflex disturbances in the nose, upper air-passages, stomach, 
and intestines, and pressure upon the bronchi of enlarged bronchial 
lymph-nodes may bring on an attack in one who is predisposed to 
them. 

Pathology. — Curschmann has described a peculiar exudate of mucin, 
which occurs in a majority of cases and which might come from a turges- 
cent mucous membrane, which gives a distinctive character to the sputum. 
Early in the attack it is expectorated as round, ball-like masses, which 
may be unfolded, representing casts of the smaller tubes ; they have been 
called the Aperies of Laennec." Microscopically these bodies have been 
found by Curschmann to have a spiral structure. Within a few clays the 
sputum becomes muco-purulent and the spirals disappear. These spirals 
occur only in pure bronchial asthma, and not in bronchitis or pneu- 
monia. 

In the sputum of both asthma and emphysema the eosinophiles are 
very numerous, and an increase of the same cells in the blood, running 
as high as 14.6 per cent., has been noted by Fink. Billings reports a case 
in which the eosinophiles were increased to 53.6 per cent., Avithout any 
increase in the total number of white cells. It is claimed by von Woorden 
and Schwerskewski that a paroxysm of asthma may be predicted by an 
increase in the number of eosinophiles. If the disease is of long stand- 
ing, we may find an associated emphysema of the lungs. 

Symptoms. — The symptoms of bronchial asthma are the same in the 
child as in the adult. A catarrhal condition of the respiratory tract, 

43 



674 PEDIATRICS. 

especially of the bronchi, commonly precedes the attack for some days. 
The onset is usually sudden, and generally occurs at night. The child is 
seized with distressing dyspnoea, mainly expiratory, the respiration being 
accompanied by a Avheezing sound. The face is anxious, and if the attack 
continues for some time it becomes slightly cyanotic. The respirations 
are not especially increased in frequency. The pulse is rapid, and when 
the dyspnoea is very intense becomes weak. The temperature is not 
raised, and when the paroxysm is prolonged it may become subnormal. 
The physical signs are mostly diffuse, sibilant, and sonorous rales, rhonchi, 
and muscular rumbles, which obscure or render inaudible the respiratory 
murmur. The attack may last for a number of hours, or even for days. 
The paroxysms vary in their severity, and, as a rule, are followed by 
considerable exhaustion. The frequency of the attacks varies ; they may 
occur often or only at intervals of months. 

Diagnosis. — Attacks of asthma are generally easily diagnosticated by the 
spasm, the history of previous attacks, and the characteristic sputum and 
blood. Cardiac, renal, and thyroid dyspnoea — that is, conditions known 
as "false asthma 1 '' — can be excluded by the examination of the blood and 
sputum and by the recognition of the respective diseases. 

Mechanical irritation of the bronchi, as by pressure of an aneurism or 
of enlarged glands, may bring on a spasm of the bronchioles resembling 
true asthma, and here again the examination of the blood and sputum are 
of great service. 

Spasm of the glottis produces a noisy dyspnoea, but the difficulty is 
with inspiration instead of expiration. The sound produced is more of 
a crow than a wheeze, and no rales can be heard in the lungs. 

Prognosis. — The prognosis of asthma with regard to the especial 
attack is good. When the disease is not hereditary the children very 
commonly recover from it as they approach the age of puberty. In many 
cases the attacks seem to depend upon some local affection of the air- 
passages, and the cure of these local lesions will often be followed by 
recovery from the attacks of asthma. 

Treatment. — In the treatment of asthma, the nose and throat should 
be carefully examined for local diseases, as the attacks may be caused by 
the different forms of rhinitis, adenoid growths, or enlarged tonsils. The 
children should be protected from unfavorable atmospheric influences, a 
high, dry, inland air usually being better suited to them than sea-air. In 
some cases, especially of a mild form, the fumes of nitre paper will give 
considerable relief. In very severe attacks hydrate of chloral may be 
given, either by the mouth or by enemata. Antispasmodics, such as bella- 
donna and lobelia, can also be used. There is no one drug which will 
relieve the paroxysms of asthma except morphine, which should be used 
with great caution. Iodide of potassium in gradually increasing doses is 
in some cases beneficial. Especial attention should be paid to the gen- 
eral hygiene and to the diet of the child. 



DISEASES OF THE BRONCHI AND LUNGS. 675 

PNEUMONIA. 

Pneumonia is an acute or subacute affection of the lungs, due to the 
action of infectious micro-organisms, the pathology, symptoms, and prog- 
nosis of which vary according to the particular bacterium which is the 
exciting cause of the inflammation. 

Two general types of the disease are usually described, according to 
the mode of invasion and to the distribution of the pathological lesions ; 
(1) lobar pneumonia, in which the whole or greater part of a lobe of the 
lung is involved, and (2) broncho-pneumonia, in which individual lobules 
of the lung are affected, forming small areas of consolidation irregularly 
distributed. 

One particular organism, the pneumococcus of Fraenkel, shows a special 
tendency to cause an inflammation of a lobar type, and such a disease, 
accurately speaking, should be termed "pneumococcus lobar pneumonia." 
It is this condition which is generally referred to when the terms " lobar 
pneumonia" " acute croupous pneumonia," or " acute fibrinous pneumonia" 
are used. 

Broncho-pneumonia, or lobular pneumonia, is, on the other hand, due to 
a number of different organisms, which will be more fully described later. 
The especial point to be emphasized in connection with the subject of 
classification is the characteristic tendency of these organisms to produce an 
interstitial inflammation of the peribronchial tissues of the terminal bronchi, 
with exudation into the neighboring alveoli and consequent consolida- 
tion of the lobules of the lungs. Such areas of consolidation may occa- 
sionally, by confluence, merge into one large mass, and end by producing 
a consolidation of the whole of a lobe, giving rise to physical signs and 
sometimes to macroscopic appearances which are essentially the same as 
a lobar pneumonia, but all cases of this variety will, on microscopic ex- 
amination, show the appearances of a lobular infection differing in many 
respects from the microscopic pathological appearances of a pneumococcus 
lobar pneumonia. Tuberculosis of the lung is essentially a broncho- 
pneumonia, but with pathological and clinical features which are so dis- 
tinctive that it is more convenient to describe it in connection with the 
general subject of tuberculosis (page 393). 

Both the lobar and the lobular or broncho-pneumonias are diseases 
due to infectious micro-organisms. In view, however, of the variety of 
etiological factors in a broncho-pneumonia, and of the occasional cases 
which bear so close a resemblance to a lobar pneumonia, and inasmuch 
as the specific organism of pneumococcus pneumonia is also, in a large 
proportion of cases, the direct cause of a broncho-pneumonia, it is much 
more convenient for the present to describe these affections together and 
in connection with the general subject of diseases of the lung. For the 
same reasons we shall not attempt to isolate the pneumococcus lobar 
pneumonia and to classify it among the specific infectious diseases. 



676 PEDIATRICS. 

PNEUMOCOCCUS LOBAR PNEUMONIA. 

Pneumococcus lobar pneumonia is an acute infectious, self-limited 
disease, characterized in typical cases by sudden onset, high fever, consoli- 
dation of one or more lobes by a fibrinous exudation into the alveoli, 
marked leucocytosis, running a course in children of from five to eight 
days and ending abruptly by crisis. 

Etiology. — Acute infections of the lungs, which are associated with a 
consolidation of the whole or greater part of a lobe of a lung, are due in 
a great majority of cases, probably in as many as 95 per cent., to the 
action of the pneumococcus of Fraenkel, which has also been called the 
micrococcus lanceolatus. This organism is, at times, also a direct cause of 
pleurisy, pericarditis, endocarditis, peritonitis, and meningitis. 

The disease is almost invariably primary. It may appear in an epi- 
demic form and run a more fatal course than in sporadic cases. It may 
occur at any age, but in the first two years of life it is rare in comparison 
with broncho-pneumonia, which is the usual form of pneumonia in 
infancy. In the third year it becomes more common, and, according to 
Osier, increases in frequency up to the sixth year, when it diminishes up 
to the fifteenth year. The proportion of cases then again begins to rise. 
Recurrent attacks of pneumococcus lobar pneumonia are not so frequent 
in young children as in adults. 

Exposure to cold and especially to sudden atmospheric changes seems 
to render the individual more susceptible to the invasion of the micro- 
organism. When this form of pneumonia occurs, as it sometimes does, 
as a secondary infection in such diseases as pertussis, measles, and scarlet 
fever, it is usually in children over three years of age (Holt). These 
secondary pneumonias are, however, much more likely to be in the nature 
of broncho-pneumonia. 

Pathology. — The pathological condition which occurs in lobar pneu- 
monia is an acute exudative inflammation which involves progressively 
the whole of one lobe, or the larger part of one lung, or portions of both 
lungs. There is no especial distinction between the lesions of lobar 
pneumonia as they occur in children and those which are met with in 
adults, except so far as the anatomical conditions differ according to the 
age of the individual. It is much more common, however, to have the 
pneumonic process begin in the apices of the lungs in children than in 
adults. Holt's statistics show that both lungs are affected with about the 
same frequency, and that the order of frequency is left base, right apex, 
right base, left apex. 

The stages of congestion, red hepatization, gray hepatization, and reso- 
lution take place in succession in the pneumonia of the child as in that 
of the adult. In the stage of congestion the lung is hypersemic and 
oedematous and the air-vesicles contain fibrin, pus, granular matter, red 
blood-cells and epithelial cells. The epithelium of the air-vesicles is 



DISEASES OF THE BRONCHI AND LUNGS. 677 

swollen, and there are large numbers of white blood-cells in the capil- 
laries. The large bronchi are congested. The small bronchi contain the 
same inflammatory products as do the air-vesicles. This stage lasts only 
a few hours, as a rule, but may be protracted for several days. When 
the exudation of the inflammatory products has reached its full develop- 
ment the presence of these products within the air-vesicles and bronchi 
causes the lung to be slightly enlarged, and at this time it is said to be in 
the condition of reel hepatization. After the air-vesicles have become 
completely filled with exudation there follows a period during which the 
exudation first becomes decolorized and then degenerated. This is the 
period of gray hepatization. This happens at a variable time, which is 
usually shorter in children than in adults. The color finally becomes 
gray. The exudate then undergoes still further degeneration and soften- 
ing, and is removed by the lymphatics. This is the stage of resolution. 
Resolution should begin immediately after defervescence and be com- 
pleted within a few days, but it may not begin until a number of days 
after defervescence, and may be unusually protracted. 

The bronchi are almost always affected in lobar pneumonia. The 
pneumonic process may occur in small patches, but usually involves an 
entire lobe. The lower lobes are the ones which are most frequently 
affected in early life, but the locality of the pneumonia is of pathological 
rather than of clinical importance, as the disease may attack any part of 
the lungs. It is generally a unilateral disease, but in some cases it may 
be bilateral. 

Symptoms. — The onset of a pneumococcus lobar pneumonia is, as a 
rule, very acute, and in the infant or young child is frequently ushered in 
by vomiting and sometimes by convulsions. The temperature rises sud- 
denly and remains high, as a rule, until the crisis. The pulse-rate is in- 
creased. The child appears profoundly infected. The face is flushed, the 
skin hot and dry. There is a short, dry, painful cough. The respira- 
tions are rapid and shallow. The alae nasi expand with each inspiration, 
and the dyspnoea is marked. The mind at first is clear, but as the 
process continues delirium and stupor assert themselves as prominent 
symptoms. In from five to seven days the disease in typical cases runs 
its course. The temperature falls by crisis. Sometimes within a few 
hours the picture changes suddenly. The breathing becomes easy, the 
skin moist and then bathed in perspiration, the pulse slow and full, the 
appetite returns, and convalescence, barring complications, is rapid. 

The individual symptoms vary so greatly in different cases that they 
can be understood best when considered separately. 

Onset. — The onset of the disease is preceded by a prodromal stage of 
a few hours only, sometimes with mild catarrhal symptoms, sometimes 
with only chilly sensations, headache, and malaise. A definite rigor is 
very uncommon under five years ; convulsions are more frequent in 
infants and are uncommon at a later period. Vomiting or diarrhoea, 



678 PEDIATRICS. 

especially in summer, are common. Pain is a fairly constant initial symp- 
tom, but the younger the child the less definitely is it localized ; it is often 
referred to the abdomen, and may suggest the pain which occurs in the 
beginning of an appendicitis. The prostration is pronounced. 

Temperature. — The temperature rises suddenly to 39.4°, 40°, or 40.5° 
C. (103°, 104°, or 105° F.) ; it remains high, with variations of one or 
two degrees in the morning and evening observations. At times the 
variations are much greater than this. In typical cases the temperature 
drops to normal with a distinct crisis, and rises again only in the case of 
reinfection or of a complication. 

Pulse. — The pulse is full and bounding at first, and somewhat accel- 
erated. As the toxins accumulate its rate increases, the tension dimin- 
ishes, and the weakening of the heart is indicated by a small, rapid, 
irregular, intermitting, or dicrotic pulse, with cyanosis and jugular pulsation. 

Respiration. — The respirations are always greatly increased, the alse 
nasi dilate in inspiration, and dyspnoea is manifested by short, labored, 
jerky breathing. The normal ratio between the pulse and respiration is 
greatly disturbed, and constitutes one of the chief features of the disease. 
Instead of being in the ratio of 1 to 3 or 4 it may be as great as 1 to 2. 
Respirations of 60 to 70 to a pulse of 120 to 140 is not uncommon 
in children. That this remarkable disturbance is not dependent upon the 
consolidation alone is evident by the change in the type of respiration 
and pulse which occurs after a crisis, when the signs of consolidation 
remain the same. 

Cerebral Symptoms. — In some cases during the height of the disease 
there is delirium. In the milder cases the delirium may be merely a 
slight wandering, but in the more severe cases the children may become 
much excited, and the delirium may be accompanied by contracted or 
dilated pupils, and even involuntary passages of urine and of fasces, with 
continual movement of the head, muscular twitchings, and other symptoms 
which may simulate closely those of cerebrospinal meningitis. In place 
of the delirium and the excited condition there may be a condition of 
stupor which sometimes simulates the stupor of tubercular meningitis. 
In another set of cases the nervous symptoms markedly simulate those 
of the non-tubercular form of meningitis. Meningitis, however, may 
sometimes actually occur in the course of pneumonia, and be due to a 
pneumococcus infection. Violence of the symptoms is not common. 
Marked cerebral symptoms seem to depend more on the height of the 
temperature and the virulence of the organism than on the extent of the 
consolidation or on any especial part of the lung being affected, such as 
the apex. In infancy and in the early years of childhood, in place of these 
cerebral symptoms there may be simply an apathetic condition during the 
height of the disease, and the infant, although somewhat somnolent and 
restless, often shows no other nervous excitement. The course of the 
disease is usually shorter in young than in older children. 



DISEASES OF THE BRONCHI AND LUNGS. 679 

Cough. — Cough is a common symptom, not only in the beginning of 
the disease, but also during its whole course, ' and often seems to be 
painful. It may, however, be absent for several days in the beginning 
of the attack. There is rarely any expectoration before the seventh or 
eighth year, and hence in infants and young children we rarely see the 
" rusty" sputum so characteristic of pneumococcus pneumonia. When 
it is obtained it is generally rusty and tenacious, and, on staining, the pneu- 
mococci are found within the leucocytes in large numbers. 

Blood. — The blood shows a marked increase in the leucocytes, which 
begins at the time of the chill. In cases in which a pseudocrisis occurs 
the leucocytosis persists, while, in certain cases, at the time of or a few 
hours before the true crisis the white blood count begins to diminish, and 
reaches its normal one or two days after the temperature. If resolution 
is by lysis, the reduction in the white cells is gradual. In delayed reso- 
lution, the leucocytosis persists, sometimes for weeks, especially if abscess, 
empyema, or gangrene develops as a complication. Cases of pneumonia 
which show an absence of leucocytosis, except in the very mildest forms, 
are generally considered of very unfavorable prognosis. A high and in- 
creasing white blood count is of value only as an aid to diagnosis, and is 
no guarantee whatever of a favorable issue. 

Urine. — The urine shows the characteristics of a febrile urine, — high 
color, high specific gravity, and increased acidity, with a slight trace of 
albumin and pure hyaline and finely granular casts. The chlorides are 
absent or greatly reduced at the height of the fever owing to the large 
amount which is deposited in the consolidated lung. At the time of the 
crisis there is often a marked increase in the amount of the urine, and the 
chlorides reappear. 

Shin. — Herpes of the nose, lips, genitals, or anus occurs not uncom- 
monly in association with pneumococcus lobar pneumonia. Redness of 
one cheek is an occasional phenomenon, but is not necessarily on the 
same side as the consolidation. Cyanosis is seen in connection with 
failing circulation. 

Digestive Organs. — The tongue is white, furred, and dry. The appe- 
tite fails, diarrhoea or constipation are apt to appear, and meteorism with 
considerable distension of the abdomen is sometimes a distressing and 
grave symptom. The spleen is usually slightly enlarged, and its edge is 
occasionally palpable. 

Crisis. — The time when the temperature falls and the crisis takes 
place varies. It may occur as early as the third or fourth day, but is 
usually between the fifth and the eighth day. It may, however, be de- 
layed until the ninth or tenth day, and in rare cases still longer. This 
rapid fall in the temperature, associated with the initial sudden rise, are 
two of the most typical and A^aluable symptoms in the diagnosis of a 
pneumococcus lobar pneumonia. When the temperature falls at the 
crisis of the disease it is very apt to become subnormal, and to remain so 



680 PEDIATRICS. 

for a number of days. Sometimes after the temperature has fallen to 
the normal it may rise again, but, as a rule, another rise of temperature 
points towards the involvement of some fresh area of the lung or to 
some complication, such as pleurisy. The fall of temperature at the 
time of the crisis is often accompanied by symptoms of great prostra- 
tion and even collapse, and it is therefore important to watch carefully 
for the crisis and to be prepared to combat these symptoms, as death 
has occurred at this time. The normal height of the temperature in 
acute lobar pneumonia, according to the extensive observations of Holt, 
is from 40° to 40.5° C. (104° to 105° F.). In children over three years 
of age the temperature curve resembles the adult type in being regular 
and falling by crisis, while under three years of age the proportion of 
typical cases is much less, and there is more irregularity in the course 
of the temperature, which may fall by lysis. The younger the individual 
the more likelihood there is to be a wide fluctuation in the range of the 
temperature, which has a tendency to be of the remittent type even in 
uncomplicated cases. Morrill and others have shown that if the fall in 
the temperature is prolonged beyond the twelfth day it is apt to subside 
by lysis. 

Physical Signs. — Inspection. — The principal features observed on in- 
spection are the flushed cheeks, herpetic vesicles about the mouth or 
nose, short, rapid, and superficial respiration, dilatation of the alae nasi, 
and sometimes deficient expansion on the affected side. 

Palpation. — In typical cases the tactile fremitus is much increased. 
If the air is excluded from the bronchi by secretions or fibrinous plugs, 
tactile fremitus is not obtained. The obstruction may sometimes be re- 
moved by a few hard coughs, and the fremitus then returns. 

Percussion. — The percussion-note over an area of consolidation varies 
from dulness to flatness ; it may be tympanitic in quality in the early and 
late stages of the disease. In the pneumonias of infants and children 
dulness is especially likely to be absent, and if the base of the lung is 
consolidated, a tympanitic quality may be obtained by transmission from 
a distended stomach or colon. Wintrich states that the minimum amount 
of consolidation, when superficial, which will produce dulness is an area 
five centimetres in diameter and two centimetres deep. 

Auscultation. — The respiration in infants and young children is normally 
somewhat harsh or broncho-vesicular in character, and should not be mis- 
taken for the tubular or bronchial breathing which is characteristic of a 
consolidation. If the tubes are filled with mucus and fibrin, the respira- 
tory sounds may be much diminished and even absent, closely simulating 
a pleural exudation. In the very early stages the breathing may be feeble 
or suppressed over the affected area, and very fine crackling or crepitant 
rales may be heard at the end of each inspiration, which disappear during 
consolidation and reappear at the beginning of resolution. Medium and 
coarse moist rales are much more common in children than the crepitant 



DISEASES OF THE BRONCHI AND LUNGS. 681 

rales. The voice-sounds are intensified, seem near to the ear (bron- 
chophony), and sometimes have a nasal quality (egophony). 

Varieties. — Certain variations in the type of pneumococcus lobar pneu- 
monia occur, and have been designated by especial names. In apex pneu- 
monia the inflammation is limited to the apex of the lung. In massive 
pneumonia the exudation fills even the bronchi, completely consolidating 
the lung, and giving rise to physical signs which can be differentiated from 
pleural exudation only by exploratory aspiration. In migratory or creeping 
pneumonia one lobe after another is involved. Cerebral pneumonias are 
simply those forms which are associated with severe cerebral symptoms. 
Some writers describe an abortive type of pneumococcus pneumonia in 
which the signs are those of the stage of congestion, and the disease runs 
a course of from twenty-four to forty-eight hours. I, myself, have not, 
however, seen in children any cases in which the evidence was sufficient 
to justify the diagnosis. 

Central pneumonia is a type of the disease especially common in 
children. The clinical symptoms are present, but the physical signs are 
absent, as the consolidation is deep-seated. The signs may not come to 
the surface for many days, or resolution may take place before they 
appear. 

Delayed Resolution. — The crisis in lobar pneumonia is not always 
accompanied by a resolution of the consolidation ; the local signs may 
persist, and disappear only in the course of several weeks. In these 
cases of delayed resolution the temperature frequently falls by lysis. 

The following case illustrates a lobar pneumonia in which resolution 
was delayed for thirty days. 

A girl, four years old, and perfectly well and strong, was suddenly attacked with 
vomiting, pain in the right side, and cough accompanied, according to her mother, by 
a reddish-brown sputum. Physical examination on the following day revealed nothing 
abnormal except a few fine moist rales at the base of the right lung behind. The 
pulse was 170, the respirations 60, and the temperature 39.4° C. (103° F.). On the 
following day the temperature still remained raised, and there was dulness on percus- 
sion over the lower right lobe behind, with bronchial respiration. On the following 
day the dulness had extended over the whole of the right lung in front and behind. 
The temperature varied from 38.8° to 39.4° C. (102° to 103° F.), the pulse from 150 
to 160, and the respirations from 50 to 60. These symptoms continued until the eighth 
day from the onset of the attack, when the temperature was found to be 38.4° C. 
(101.2° F.), the respirations 48, and the pulse 160. During the next nine days the 
temperature, pulse, and respirations remained the same, and there was no change in 
the physical signs of the lung, except that in addition to the dulness and bronchial respi- 
ration a number of fine moist rales were heard in the back and in the axillary regions. 
During the next week no change took place in the temperature, pulse, respiration, or 
physical signs. Some days later the temperature fell to the normal, the respirations to 
36, the pulse to 135, the dulness began to disappear, and the numerous coarse and 
fine moist rales of resolution appeared. Resolution took place rapidly, and a week 
later, thirty days from the onset of the attack, the lung appeared to be in a perfectly 
normal condition. From that time the child gained rapidly in strength and weight and 
recovered completely. 



682 PEDIATRICS. 

The following cases illustrate the type of a central pneumonia. They 
showed the clinical symptoms of a lobar pneumonia, quick respirations, 
rapid pulse, dilatation of the alee nasi, apathy, delirium, and vomiting, but 
the physical signs did not appear in the lung for a number of days. The 
whole course of the disease and the physical signs were so similar in both 
instances that one description will suffice for both. 

There were two boys, brothers, the older boy being three years and the younger 
sixteen months old. The older boy was attacked on November 19, and the younger 
one on November 20, with continuous vomiting, which lasted without much inter- 
mission until November 26. In addition to the vomiting the temperature rose in the 
first twenty-four hours to 40.5° C. (105° F.), and until November 26 varied from 40° 
to 40.5° C. (104° to 105° F.). The respirations varied from 40 to 50, and the pulse 
from 150 to 160. Both children soon became unconscious, were very restless, rolled 
their heads continuously, and showed contracted pupils. On November 26 the tem- 
perature fell to 39.4° C. (103° F.), and during the next two days varied from 39.4° 
to 40° C. (103° to 104° F.). On November 27 a small area of flatness with bronchial 
respiration was detected in the older boy over the left upper lobe in front, and on the fol- 
lowing day in the younger boy over the left lower lobe behind. After the first few days 
there was slight cough in both cases, with movement of the alas nasi. On November 30 
the temperature in both children rose to 40.5° C. (105° F.), and until December 2 it 
varied from 40° to 40.5° C. (104° to 105° F.). On the evening of December 2 the tem- 
perature in the older boy suddenly fell from 40.5° C. (105° F.) to 35.5° C. (96° F.). 
The child became cold, the pulse became feeble, and the respiration could scarcely be 
detected. The application of a hot pack and an enema of hot brandy-and-water 
rapidly revived the child. The same fall of temperature occurred in the other boy on 
the following morning. In both children signs of resolution were detected before the 
temperature fell, the lungs in both cases rapidly became normal, and after a short 
convalescence the children recovered completely. 

In some cases lobar pneumonia may attack both lungs. Again, after 
the disease has run its course and the temperature has fallen to nor- 
mal, a fresh portion of the lung may be involved and the temperature 
may rise again. In rare instances in otherwise typical cases of lobar 
pneumonia I have been unable to detect any rales over the area of solidi- 
fication throughout the whole course of the disease. 

Complications and Sequels. — The complications of pneumococcus lobar 
pneumonia are not numerous. 

Pleurisy always occurs if the inflammation is superficial. It may be 
dry, fibrinous, sero-fibrinous, or purulent (empyema). The presence of 
exudation renders the diagnosis much more difficult, and aspiration is 
usually necessary to determine the condition. 

Pericarditis may occur, and is more common in children than in 
adults. It is frequently associated with pericardial exudation, which is 
either serous or purulent. Recovery may occur even in a purulent peri- 
carditis (Murchison). 

Otitis media is not an infrequent complication in children. Often the 
only suggestion of its presence is a sudden rise in the temperature. 

Gangrene of the lung is of very rare occurrence, but may be the 



DISEASES OF THE BRONCHI AND LUNGS. 683 

terminal process of a delayed resolution. In the same way an abscess of 
the lung may develop ; it may perforate into the pleural cavity and pro- 
duce an empyema, or into a bronchus and the pus be expectorated. 

Other rare complications due to the pneumococcus are meningitis, 
endocarditis, and peritonitis. 

Diagnosis. — The diagnosis of pneumococcus lobar pneumonia, when 
the typical temperature and the characteristic physical signs are present, 
is not difficult, but there are a number of atypical cases in which a doubt 
might easily arise for a number of days after the invasion of the disease. 
When a specimen of the sputum can be obtained, the character of the 
infection can often be determined at once, even when the physical signs 
are not distinctive, by a bacteriological examination in reference to the 
presence of the pneumococcus in large numbers, alone or associated with 
other organisms, within the leucocytes. 

From Pleural Exudation. — An early diagnosis from a pleural exudation 
is at times impossible, and is always quite difficult in the early stages 
before the characteristic signs of consolidation have been established. In 
both diseases dulness or flatness over a limited area, and bronchial respi- 
ration without any especial difference in the tactile fremitus and vocal 
resonance, and without evidence of a friction-rub or of rales, may make 
the two diseases simulate each other closely and compel us to wait for 
further developments before determining the differential diagnosis. This 
similarity in the signs of fluid and consolidation is especially characteristic 
in children. In typical cases of pleural exudation the absence or marked 
diminution of tactile fremitus and vocal resonance, the shifting character 
of the area of dulness on change of position, the diminished intensity of 
the respiratory sounds, bulging of the intercostal spaces, and displace- 
ment of the heart, and of the liver in exudations on the right side, are 
signs which render definite the diagnosis from a consolidated lung. In 
atypical cases, however, the signs may so closely resemble those of pneu- 
monia that the diagnosis can only be made by exploratory puncture. 

From Tuberculosis of the Lung. — In tubercular disease of the lung the 
differential diagnosis is usually not difficult, except in young infants, in 
whom the tubercular process with its corresponding symptoms may in 
rare cases simulate lobar pneumonia. The onset of the symptoms, the 
course of the disease, and the examination of the sputum, will, in nearly 
all uncomplicated cases, make the diagnosis clear. 

From Broncho-Pneumonia. — The disease from which a differential 
diagnosis should especially be made is broncho-pneumonia. Lobar pneu- 
monia and secondary broncho-pneumonia are so distinct, however, in 
their previous history, initial stage, course, and duration that, if care be 
taken to note closely all these stages of the two diseases and to arrive at 
a diagnosis from the evidence given by all the stages and not by any one 
stage, the diagnosis can, except in the very early days of the disease, 
usually be determined. Lobar pneumonia, in contradistinction to the 



684 PEDIATRICS. 

secondary form of broncho-pneumonia, is a primary disease, characterized 
by a sudden onset and a regular temperature, which rises abruptly. This 
is accompanied by a corresponding rapidity of the pulse and respirations, 
dulness on percussion usually involving and limited to one lobe or one 
lung, with increased vocal fremitus and resonance, and bronchial respira- 
tion over the dull area. This is followed by a fall of temperature and by 
a rapid resolution. The duration is short and definite. Broncho-pneu- 
monia, on the other hand, is usually secondary to a preceding bronchitis, 
occurring either alone or in the course of some other disease. It is charac- 
terized by a slow and insidious onset, except when it occurs in the course 
of measles ; it has an irregular temperature, the rise usually not being so 
sudden or so high as in lobar pneumonia, and the respirations and pulse 
slowly increase with the temperature. There is often an absence of 
change in percussion, the dulness if present showing itself in small 
patches and commonly in both lungs. There is also often an absence of 
marked vocal fremitus or vocal resonance, and of bronchial respiration, 
except where the patches of dulness are pronounced. Moist rales of all 
sizes may be heard in circumscribed areas throughout both lungs. The 
temperature is usually of a remittent type, and this condition lasts for weeks 
rather than days, the duration often being prolonged. If these pictures 
of the two diseases are borne in mind, an error in the differential diag- 
nosis will seldom be made. In the doubtful cases, in which the character- 
istic course of either disease is absent, it will usually be found that we 
are dealing with a case of broncho-pneumonia, which is an exceedingly 
variable disease, rather than with lobar pneumonia, in which some of the 
characteristic features of the disease are almost invariably present. 

The primary forms of broncho-pneumonia, as described on page 691, 
are very difficult to differentiate from acute pneumococcus pneumonia, 
especially when the consolidation is central, and in these cases we are 
generally obliged to wait until the physical signs have become distinctive. 

Another condition in which the diagnosis is very obscure occurs in 
those cases of broncho-pneumonia in which the areas of consolidation 
have, by confluence, involved the whole or a greater part of a lobe. 

From Meningitis. — Pneumonia in children may be entirely masked by 
the intensity of the cerebral symptoms. In making the diagnosis between 
pneumonia and meningitis it is of much aid to remember that the slow 
intermittent pulse, slow irregular respiration, and moderate temperature 
of meningitis are uncommon in lobar pneumonia, in which in most cases 
the pulse is rapid and regular, the respirations rapid, and the temperature 
high. It is not uncommon, however, to find irregularities and intermis- 
sions in the rapid pulse of pneumonia. The younger the individual the 
more likely are the symptoms of tubercular meningitis to be replaced by 
those of the non-tubercular form of the disease, which may often simu- 
late closely the symptoms of pneumonia. The convulsions which occur 
in pneumonia do not differ from those which occur in meningitis, or, in 



DISEASES OF THE BRONCHI AND LUNGS. 685 

fact, in any other acute disease. A careful physical examination should 
be made at every visit, once or twice a day if possible, as in this way the 
masked symptoms of a pneumonia may at times be detected where they 
would be overlooked if only an occasional examination w T ere made. 
After the first four or five days, as a rule, the differential diagnosis be- 
tween cerebral disease and pneumonia is not difficult. Lumbar puncture 
is of much value in the diagnosis of meningitis in these cases. 

From Influenza. — The presence of a well-marked leucocytosis is of 
much service in excluding influenza, but the possibility of an influenza 
pneumonia must be borne in mind. In the latter case, if leucocytosis is 
present at all, it is rarely high, and the examination of the sputum, the 
course of the disease, and the character of the physical signs generally 
make the diagnosis clear. 

From Malaria. — The onset of malaria may closely resemble that of 
lobar pneumonia, but its subsequent course is essentially different. A 
chill with a sharp rise in the temperature, associated with a marked leu- 
cocytosis, is rarely, if ever, due to malaria. 

Prognosis. — The prognosis of pneumococcus lobar pneumonia is very 
favorable. In young infants, or in those who are weak and debilitated, it is 
often fatal, but in comparison with broncho-pneumonia the percentage of 
recovery is very high. When the temperature rises to 41.1° C. (106° F.) 
the prognosis is usually grave. The convulsions which occur in the 
initial stage of the disease in infants are commonly not of grave import. 
Occurring late in the disease they make the prognosis very unfavorable. 
When delirium occurs, although it may be severe, it does not render the 
prognosis especially bad. The fulminant type of the disease which some- 
times occurs is a very fatal form. 

Treatment. — As lobar pneumonia is a self-limited disease of short 
duration, the children are not so apt to die of exhaustion, and, as a rule, 
only an expectant treatment is called for. 

Nursing and General Hygiene. — The child should be placed in a 
room of an equable temperature of 20° or 21.1° C. (68° or 70° F.), and 
should be given milk every two hours. There is no necessity for making 
any external applications to the chest. The use of poultices is to be dep- 
recated, and in my experience is usually without benefit except in cer- 
tain instances for the relief of pain. The nursing is of especial importance, 
■and close watchfulness, especially at the time when the crisis is expected 
to take place. At this time the temperature in infants and young children 
may fall with such rapidity to several degrees below the normal point 
that collapse often takes place, the skin is cold and moist, and sometimes 
the child becomes unconscious. Under these circumstances the pulse is 
feeble and intermittent, and in some cases death may occur unless active 
measures are taken for establishing reaction. The nurse should therefore 
be warned as the time of the expected crisis approaches to watch the 
child both night and day, and to have remedies ready to be used in case 



686 PEDIATRICS. 

serious symptoms should arise. These remedies should be the external 
application of heat by means of the hot pack, and the administration of 
brandy by the mouth if the child can swallow, otherwise by rectal in- 
jection. I have known of a case where a child died in the collapse fol- 
lowing the crisis of a lobar pneumonia. It is often not necessary to use 
any remedy whatever, and it is safer to wait until there are indications 
for the use of drugs. There is no remedy which will shorten the course 
of the disease. Cardiac weakness, hyperpyrexia, pain, and toxaemia are 
the four indications which require special symptomatic treatment. 

Cardiac Weakness. — The condition of the circulation should be care- 
fully watched. When the disease occurs in very young infants it is safer 
to administer stimulants from the beginning. Brandy, or whiskey, and 
strychnine are the most serviceable drugs for a cardiac stimulant. The 
brandy should be adapted to the age of the child as given on page 456, 
and the strychnine as stated on page 470. The limits of administration 
will depend upon the way in which the heart responds to the stimulant. 
Inhalation of oxygen often gives great relief when there is cyanosis and 
marked dyspnoea. Aromatic spirits of ammonia may also be used to 
supplement the alcoholic stimulation. 

Hyperpyrexia. — Although at times a high temperature does not neces- 
sarily indicate danger, since a temperature of from 40° to 40.5° C. (104° 
to 105° F.) is part of the regular course of the disease, yet if the tempera- 
ture rises above this point it is well to reduce it by means of bathing and 
to give alcoholic stimulants. When the child does not react well to the 
bath, phenacetine in doses of 0.06 to 0.12 gramme (1 to 2 grains) will 
often keep the temperature down for several hours. It should be guarded 
with stimulants. It must, however, be understood that it is not the height, 
of the temperature so much as the intensity of the nervous symptoms 
which determines the indication for antipyretic treatment. 

Pain. — Pain is often a distressing symptom, and may at times require 
small doses of paregoric, adapted to the age of the child. From one to 
three months, 0.06 to 0.12 c.c. (1 to 2 minims) may be given; at one 
year, 0.3 to 0.6 c.c. (5 to 10 minims); and at five years, 1.8 to 2.4 c.c. 
(30 to 40 minims). The application of ice-poultices is indicated in these 
cases, but only for short periods. 

Toxaemia. — Although extensive investigations have been made in regard 
to the serum therapy of pneumococcus lobar pneumonia, the efficiency, 
and expediency of the treatment is still in doubt. The only means we 
possess of combating the toxins is by reduction of the fever and by 
general supportive treatment. 

Convalescence. — During convalescence the child should be carefully 
protected from atmospheric changes, cold, and dampness for some months, 
and its food and habits should be carefully regulated. 

Lobar pneumonia may occur in the earliest days of life. I have met 
with a case which on the third day of its life developed a lobar pneu- 



DISEASES OF THE BRONCHI AND LUNGS. 



687 



monia and died in twenty-four hours. The autopsy showed the char- 
acteristic hepatization of lobar pneumonia. 

The following case illustrates lobar pneumonia : 



CHART 28. 



A boy, eight years old, entered the hospital on the fourth day of an attack of lobar 
pneumonia. The attack began with vomiting and cough, but no pain, expectoration, 
or chill. An examination showed the right lung to be normal. On the left side of 
the chest an area corresponding to the lower lobe in the back 
was found to show dulness on percussion, bronchial respira- 
tion, and many fine moist rales. Nothing else abnormal was 
detected. The child was very restless, but on the following 
day, the fifth from the onset of the disease, the temperature 
fell by crisis to the normal point. Chart 28 shows the typical 
temperature, pulse, and respiration of a case of lobar pneu- 
monia. 

After the crisis the child improved rapidly, and the 
physical signs disappeared in ten days. 

A girl, two and a half years old, entered the hospital on 
the third day of an attack of lobar pneumonia. Chart 29 
shows one of the variations in the crisis which is quite fre- 
quently met with in young children. The temperature in 
this case reached the normal on the tenth day. 

In this case the consolidated portion of the lung was the 
left lower lobe. The resolution was rapid and convalescence 
normal. 

A girl (Fig. 143), eight years old, had pertussis when she 

CHART 29. 





Days of Disease. 


K. 


4 


5 


6 




c. 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 

•OP 9 -?" 

Tt«P 

88 
97° 
06° 
05° 


M E 


M E 


M E 


M E 


M E 


41 6° 

411" 

40.5* 

40.0* 

39.4* 

38.8° 

38.3* 

37.7* 

37.2* 
37.0* 

36.6* 

36.1* 
35.5* 
35.0* 






















/ 










/ 












































V 










\ 










\ 








































150 
140 
130 


























\ 










\ 








110 
100 
90 
80 
70 


























\ 










\ 


























50 
45 
40 
35 
30 
25 
20 
15 
10 












1 
0* 




/ 



























































































Days of Disease. 




V. 


3 


4 


5 


6 


7 


8 


9 


10 


c. 


107° 
106° 
105° 
104' 
103° 
102° 
101° 
100° 

08 
07° 
06° 
05° 


ME 


M E 


M E 


M E 


M E 


M E 


11 B 


M E 


41.6* 
41.1* 
40.5* 
40.0* 
30.4* 
38.8* 
38.3' 
37.7* 
37.2' 
37.0" 
36.6' 

36.1' 
35.5* 
35.0°" 




































s 




/ 




































/ 
















/ 
















/ 
















/ 























































































Lobar pneumonia. Male, 
8 years old. Crisis on 
fifth day of disease. 



Lobar pneumonia. Irregular crisis on eighth 
day. Female, 2% years old. 



was fourteen months old, scarlet fever when she was five years old, and measles when 
she was six years old. Five days before entrance she lost her appetite, was very 
feverish, and was attacked with acute pain referred to the left side of the epigastrium 
and the lower part of the left axillary region. This was accompanied with a hacking 
paroxysmal cough, with no expectoration. She became delirious, vomited occasionally, 
and was very weak. Her tongue was heavily coated, the alae nasi moved with respira- 
tion, her face was deeply flushed, and the dyspnoea was so severe that she had to be 
propped up on pillows. 

Her respirations were 45, difficult and painful, her pulse 120, and her tempera- 



688 



PEDIATRICS. 

Fig. 143. 




Lobar pneumonia. Female, 8 years old. The part of the lung involved by the pneumonic process 
is shown by black lines, and the area of diminished resonance and the tine rales are marked by black 
spots. 



Fig. 144. 



0&>*& 





Lobar pneumonia. Three invasions. Male, 6 years old. 



„d\. 



DISEASES OF THE BRONCHI AND LUNGS. 



689 



CHAKT 30. 



ture 39.5° C. (103.2° F.). A physical examination detected nothing abnormal in the 
front of the chest or in the right back. There was flatness in the left back, beginning 
at the fifth rib and extending to the base of the lung and into the axillary region. 
Over this area there was increased vocal fremitus and bronchial respiration, and a few 
moist rales. Just above the upper border of the area of flatness there were diminished 
resonance and a number of fine rales. Although the examination was made on the 
fifth day of the disease, the physical signs showed that resolution had begun and that 
the crisis might be expected at any time. 

On the following day the temperature fell to 37.7° C. (100° F.) in the morning, 
but rose again in the evening to 39.1° C. (102.5° F.). On the following day, the 
seventh day from the beginning of the attack, 
the temperature fell to 37.2° C. (99° F.), 
and then varied from 37.7° C. (100° F.) to 
37.2° C. (99° F.) until the eleventh day, 
when it became normal. The pulse and 
respirations declined synchronously with the 
temperature. 

This case illustrates the fact that the 
physical signs of resolution may sometimes 
appear before the temperature falls and the 
crisis comes ; also that at the time of the 
crisis the temperature may fall, then rise 
again for from twelve to twenty-four hours, 
and then fall to the normal. The child re- 
covered completely. 

Another child, a boy (Fig. 144), six 
years old, was taken sick four days before 
entering the hospital. 

On entering the hospital his pulse was 
128, his respirations 60, and his temperature 
39.8° C. (103.8° F.) A physical examina- 
tion showed that there was flatness over the 
entire upper lobe of the right lung ; over 
this area there were bronchial respiration, 
increased vocal resonance, and an occa- 
sional high-pitched rale. The left lung was 
normal. The lower border of the dulness 
produced by the consolidated upper lobe has 
been marked by a black line extending from 
the sternum just above the right mamma 
and around into the axillary region. On 
the morning of the sixth day from the be- 
ginning of the attack the temperature fell 
to 37.7° C. (100° F.). but rose again in the 
evening to 40.5° C. (105° F.) and a physical 
examination then showed that the middle 

lobe of the right lung was involved in front, as indicated by the second black line 
below the one just described. The temperature during the next two days remained 
between 39.4° and 40° C. (103° and 105° F.), but on the following day, the ninth from 
the onset of the disease, the temperature suddenly fell to 37.6° C. (99.7° F.) in the 
evening, but rose the next morning to 39.3° C. (102.8° F.), and in the evening was 
39.8° C. (103.8° F.). A physical examination then showed that the whole of the 
lower lobe was involved, as indicated by the third black line. On the following day 

41 





Days of Disease. 




F. 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


16 


17 


c. 


107° 
106° 
105° 
104° 
103° 
102 
101° 
100 
99 

T 98 c 
97° 
96° 
95 


ME 


U E 


U E 


ME 


H E 


U E 


M E 


ME 


ME 


ME 


M E 


M E 


ME 


41 6° 
41 1° 
40.5° 
40.0° 
39.4° 
38.8° 
38.3° 
37 7° 

37.2° 
37.0° 
36.6° 

36.1° 
35.5° 
35.0° 






















































I 


j 
























-J 


/ 


/ 


/ 




/ 
























\ 


/ 




\ 














/ 






\ 




/ 


\ 














/ 






\ 






\ 


,--' 


















\ 






























































s 


> 


^^—~ 
















































































150 
140 
130 
120 
110 
100 
90 
80 
70 
60 




























! 






























/ 










/ 












~\ 


/ 






K 




k 


/ 














r^ 




\ 








\ 




























V 






























/ 



















































































50 
45 
40 
35 
30 
25 
20 
15 
10 




/ 


s 


^ 


\ 


\ 
















a 

•2 

1 










\ 






















1 






<y 


















1 








X] 




























o- 1 






/ 







































































































































Lobar pneumonia of the migratory type. Male 
6 vears old. 



690 PEDIATRICS. 

the upper lobe began to show evidence of resolution, and the temperature fell to 
38.3° C. (101° F.). Two days later the temperature began to fall by lysis, the physical 
signs of the upper and middle lobes entirely disappeared, and the temperature reached 
the normal point on the fourteenth day from the time of the onset. On the seven- 
teenth day from the time of the onset the lower lobe was also found to be in a normal 
condition, and from that time convalescence was uninterrupted. 

Chart 30 shows the temperature, pulse, and respirations in this case from the fifth 
to the seventeenth day of the disease. 

In some rare cases the infection in lobar pneumonia is so overwhelming 
that. a rapidly fatal issue may occur. 

I have seen a little girl, nineteen months old, who had been having so mild an 
attack of diarrhcea that she was playing about out of doors, suddenly attacked in the 
afternoon with convulsions and a temperature of 40.5° C. (105° F.). The convulsions 
continued during the night, and she soon became comatose. On the following day 
the temperature still remained at 40.5° C. (105° F.), the respirations were much 
accelerated, and the pulse was about 120. An area of absolute dulness over the left 
lower lobe behind, with bronchial respiration and increased vocal resonance and fremitus, 
rapidly developed. The child did not respond to treatment, and died in the evening. 

LOBAR PNEUMONIA DUE TO OTHER ORGANISMS. 

It occasionally happens in a very small percentage of cases, as has 
already been stated, that in an acute infection of the lung an entire lobe, 
or the greater part of a lobe, may become consolidated in conditions 
other than that of a pneumococcus lobar pneumonia. This fact and the 
custom of applying the term " lobar pneumonia" to inflammations of the 
lung produced by the pneumococcus have led to more or less confusion in 
the description of the etiology and classification of the various forms of 
pneumonia. Reference has already been made on page 434 to the rare 
cases of total consolidation of a lobe occurring as a result of an infection 
of the lung by the diplococcus intracellularis secondary to an epidemic 
cerebrospinal meningitis. Other cases occur in which the pneumococcus 
is found in a mixed infection, associated with some form of pus-producing 
organism, such as the staphylococcus pyogenes aureus and the strepto- 
coccus pyogenes, or with the bacillus of influenza, the bacillus of Fried- 
lander, the Klebs-Loeffler bacillus, and rarely the typhoid bacillus. More- 
over, there is the class of cases in which the etiology and pathology are 
those of a pure broncho-pneumonia, in the course of which all the lobules 
of the affected lung have become confluent, giving rise to the gross ap- 
pearances and physical signs of a lobar consolidation. Whether a lobar 
pneumonia with the gross and microscopic appearances of a typical 
pneumoccoccus lobar pneumonia can ever be due to a single organism 
other than the pneumococcus is a question which the present state of our 
knowledge of the etiology and pathology of the disease does not warrant 
us in answering definitely. 

Lobar pneumonias which are caused in the manner just outlined 
often differ in their clinical symptoms and course from those of a pneu- 



DISEASES OF THE BRONCHI AND LUNGS. 691 

mococcus lobar pneumonia. They are much more apt to be subacute at 
their onset, secondary to some other infection, and to run a more irregular 
course, resembling closely that of a broncho-pneumonia. The bacterio- 
logical examination of the sputum is of the greatest aid in these cases, and 
may often, in connection with the clinical symptoms and physical signs in 
the early stages of the disease, enable us to make a differential diagnosis. 
Treatment. — The treatment is symptomatic, and does not differ from 
that of pneumococcus lobar pneumonia or of broncho-pneumonia. 

ACUTE BRONCHO-PNEUMONIA. 

Acute broncho- or lobular pneumonia is an infection of the lung 
characterized by an inflammation of the walls of the terminal bronchi 
and of the neighboring alveoli which make up a pulmonary lobule, and 
is so called in contradistinction to lobar pneumonia. 

Etiology. — All forms of broncho-pneumonia are produced by patho- 
genic organisms. The disease may be primary or secondary, acute or 
chronic. It may occur at any age, but is the most common and fatal 
form of inflammation of the lung during the first five years of life, and is 
much more fatal than pneumococcus lobar pneumonia during this period. 

The primary forms may attack children in good health, and usually 
under two years. It is probable that the pneumococcus is usually the in- 
fecting organism in these cases, and that the lobular rather than the lobar 
type of the disease is determined by the greater susceptibility of the lung 
from its embryonic type to the kind of inflammatory lesions which char- 
acterize a broncho-pneumonia. The bacillus of Friedlander and the 
bacillus of influenza produce this especial type of pneumonia. 

The secondary forms are much more frequent than the primary forms, 
and are very apt to be the result of a mixed infection of streptococci, 
staphylococci, and pneumococci. They are especially fatal in infants and 
young children. They occur in connection with the infectious fevers, and 
with the group called the aspiration or deglutition .pneumonias, which some- 
times follow vomiting of food, especially after ether, haemoptysis, bronchi- 
ectasis, and empyema. The relative frequency in 443 cases, according to 
Holt, is as follows: primary, without previous bronchitis, 164; secondary 
to measles, 89 ; whooping-cough, 66 ; diphtheria, 47 ; bronchitis, 41 ; acute 
ileo-colitis, 19 ; scarlet fever, 7 ; influenza. 6 ; varicella, 2 ; and erysipelas, 2. 

Children who are weak or debilitated by previous diseases show a 
predisposition to broncho-pneumonia, which frequently arises in the 
course of tuberculosis, chronic gastro-enteric diseases, and rhachitis. 
Those seasons of the year which are marked by cold, moisture, and 
variations of temperature especially predispose to the development of 
broncho-pneumonia. All these conditions, however, in all probability 
merely prepare the way for the entrance of certain germs Avhich produce 
the disease. The origin of broncho-pneumonia from intestinal infection 
must also be considered. 



692 



PEDIATRICS. 



Pathology. — In broncho-pneumonia the inflammatory process affects 
the walls of the smaller and terminal bronchi, which become thickened 
and markedly infiltrated with cells. The inflammatory process then ex- 
tends through the walls of the bronchi to the surrounding air-vesicles as 
well as to the terminal ones. In this way centres of consolidation are 
formed in different parts of the lung. The course of the inflammation 
varies in its rapidity, at times attacking only a small portion of the lung, 
and again being more diffuse in its onset and gradually invading large 
areas. The lesions are irregular in their distribution and usually occur in 
both lungs. They are at times so extensive as to involve a whole lobe, 
but, as has been stated by Northrup, whatever the extent of hepatization, 
whatever the time occupied in its course, and whatever the post-mortem 
appearances, the essential lesion is an inflammation of the walls of the 
terminal bronchi and of the adjacent alveoli. 

Fig. 145. 




Broncho-pneumonia complicating measles. Early stage. C. L. T., consolidated lung-tissue; Br., bron- 
chiole; L. T., emphysematous lung-tissue. 



Fig. 145 represents the section of a lung made by Northrup, and 
taken from an infant sixteen months old, in whom the broncho-pneu- 
monia was a complication of measles. It shows the early pathological 
lesions of broncho-pneumonia. 

In one of the lobules there are two bronchioles (Br.) with infiltrated 



DISEASES OF THE BRONCHI AND LUNGS. 



693 



walls and pus within them. They are also filled with exudation, and the 
lumen of each is almost entirely occluded. A portion of a neighboring 
lobule is consolidated (C. L. T.). A considerable portion of the lung 
tissue (L. T.) in the section is normal or emphysematous. 

Fig. 146 represents another section taken from the lung of the same 
child, but showing the tissue relatively less affected. Many of the con- 



Fig. 146. 




Broncho-pneumonia secondary to diphtheria. Br., bronchus : C. L. T., consolidated lung-tissue ; 
N. L. T... lung-tissue nearly normal ; Art., artery. 

solidated alveoli contain free blood-cells. The bronchial wall (Br.) is in- 
filtrated and almost entirely denuded of its lining membrane. These 
smaller bronchi are surrounded by zones of intense congestion and infil- 
tration. When the inflammation is intense and is accompanied by 
abundant secretion these bronchi frequently become dilated. This dila- 
tation is associated with a weakened condition of the bronchial walls and 
with an abundant secretion. These dilatations probably, according to the 
observations of Northrup, wholly disappear on the recovery of the 
patient. 

As has already been described in the pathology of bronchitis, the 
bronchial lymph-nodes are always enlarged in broncho-pneumonia, and 
there may be fibrin on the pulmonary pleura. In the zones of peri- 
brcnchitic pneumonia the walls of the air-vesicles are thickened or 



694 PEDIATRICS. 

swollen, either with or without some cellular infiltration, and the cavities 
of the air-vesicles are filled with epithelial cells and pus-cells, with fibrin 
and red blood-corpuscles in varying proportion and amount. Fibrin 
when present is only in small quantities, and often is altogether absent. 
The capillaries in the walls of the vesicles are congested and prominent. 
The portions of lung which are not hepatized are congested and (Edem- 
atous. The cavities of the air-vesicles are diminished by the enlarged 
capillaries and the swollen vesicular epithelium. 

In addition to the other lesions just described, areas of atelectasis are 
frequently found in broncho-pneumonia. This atelectasis is usually pro- 
duced by mechanical causes, such as obstruction by pus or tenacious 
mucus. It may also arise as a result of enfeebled respiratory power. 
The blood-vessels become dilated, the walls of the alveoli partially col- 
lapse, the residual air is absorbed, and an exudation of serum with pro- 
liferative cells and. leucocytes takes its place. The atelectasis is commonly 
symmetrical, affecting the posterior margin of both lower lobes of the 
lung, but it may also appear in irregular scattered areas in the posterior 
portions of the upper lobes. It may occur either during the acute stage 
of the inflammation or later when the pneumonia has become chronic. 

There are no distinct stages in the pathology of broncho-pneumonia 
Avhich correspond to those of lobar pneumonia. Broncho-pneumonia 
develops by the irregular invasion of successive portions of the lungs, 
and the process resolves in like manner. The different consolidated areas 
in the same lung may often show all the stages. The mottled appearance 
which is so often noticed macroscopically in these lungs may be caused by 
the presence of lobules of gray and red hepatization lying side by side. 
Of these inflammatory products the fibrin disintegrates quickly, and is 
therefore absorbed more rapidly than the cellular elements, which do not 
disintegrate so readily. In lobar pneumonia, therefore, absorption takes 
place sooner than it does in broncho-pneumonia, in which the products 
of inflammation are mostly cellular and resolution and absorption are 
naturally slow. 

Instead of the gradual disappearance of the various pathological lesions 
the pneumonia may persist. This persistent form of the disease may 
follow a single attack of acute broncho-pneumonia, or there may be several 
acute atta'cks before the chronic condition becomes evident, and the 
course of the disease may thus vary in different cases. When this per- 
sistent broncho-pneumonia occurs, the proliferative cells take part in the 
formation of new connective tissue, and in this way persistent thickening 
is caused. The alveolar walls of certain portions may become similarly 
thickened. The walls of the bronchi and their surrounding tissue are es- 
pecially subject to a persistent thickening and a formation of new connective 
tissue constituting chronic broncho-pneumonia and peribronchitis. The 
bronchi already dilated become still more enlarged by the contraction of 
the cicatricial tissue surrounding them. The uneven contraction of this 



DISEASES OF THE BRONCHI AND LUNGS. 



695 



new tissue, together with the pressure within the tubes facilitated by a 
weakened condition of the walls, allows of saccular as well as of fusiform 
dilatation of the bronchi. The epithelial cells of the dilated bronchi pro- 
liferate, and, falling from the bronchial walls, mix with the bronchial 
secretion. The remaining epithelium is swollen and loose. The lesions 
of chronic broncho-pneumonia are frequently associated with tuberculosis 
of the bronchial nodes and with other tubercular lesions. 

In connection with the pathological lesions occurring in chronic 
broncho-pneumonia a condition called fibroid phthisis has in very rare 

Fig. 147. 




Chronic broncho-pneumonia. Br. dl., dilated bronchus; Th. L. T., thickened lung-tissue 
Br. Pn., broncho-pneumonia. 



cases been noticed in children. The lesions which represent fibroid 
phthisis are manifested by the presence of connective tissue in the lung, 
with a corresponding destruction of the true parenchyma. These 
changes are usually unilateral, and should not be considered as repre- 
senting a disease, since they merely occur in the course of various chronic 
pulmonary affections, among which are tuberculosis and chronic broncho- 
pneumonia. 

Fig. 147 represents a section, also made by Dr. Northrup, taken from 
a lung with chronic broncho-pneumonia in which the process had ad- 
vanced still further than in the other. 



696 PEDIATRICS. 

In the middle of the specimen is a dilated bronchus with a section of 
a blood-vessel just below it. There is considerable connective-tissue 
formation about both. In this case the process of a peribronchitic 
pneumonia has gone further than in the other specimen (Fig. 145), and 
there is, in addition to the dilated bronchi with the surrounding cellular 
infiltration, a tendency to the formation of connective tissue in the inter- 
lobular septa. This is the form of chronic broncho-pneumonia which is 
sometimes called interstitial pneumonia, and is usually characterized by a 
long course and delayed recovery. 

A frequent lesion which occurs in the course of broncho-pneumonia 
is emphysema. It is usually vesicular and situated in the anterior portion 
of the upper lobes. It is due to the diminished amount of air-capacity, 
together with the violent introduction of air into the chest caused by 
dyspnoea and coughing. This distention of the air-vesicles is supposed 
usually to disappear with the subsidence of the lesion which is causing the 
emphysema. Emphysema, both of the vesicular and of the interstitial 
variety, most commonly occurs in the pneumonia which follows pertussis. 

The interstitial variety may exist in the form of superficial sacs, formed 
by the rupture of air-vesicles beneath, which lift the pleura, or it may 
extend between the lobules in V-shaped tracts from the anterior edge of 
the upper lobe even to the root of the lung. 

Symptoms. — The symptoms of broncho-pneumonia vary greatly in their 
onset and course, owing to the many different lesions which commonly 
occur in the disease and which by their greater or less severity make its 
course exceedingly irregular. In so many instances the broncho-pneu- 
monia is secondary to some other disease that the symptoms are neces- 
sarily modified by those of the initial affection. Thus, when broncho- 
pneumonia arises in the course of diphtheria, the symptoms are often 
obscured by the severity of the general symptoms of the diphtheria. 
When broncho-pneumonia is secondary to measles and to pertussis, 
although at times its onset is difficult to detect, yet, as a rule, the rapid 
respirations, the marked and continuous rise of temperature, and the 
evident exacerbation in the severity of the pulmonary symptoms, usually 
permit a diagnosis to be made even before the physical signs have become 
prominent. Its onset, however, in measles is, as a rule, rapid, while in 
pertussis it is slow and insidious. 

The group of symptoms which characterizes a broncho-pneumonia 
arising during the course of bronchitis is somewhat more definite. In 
place of the moderate temperature and the absence of signs of serious 
disease which are usually met with in the course of an ordinary bron- 
chitis, when broncho-pneumonia supervenes the temperature rises, the 
pulse and respirations are increased in frequency, the alee nasi dilate, 
there is more or less cyanosis, the cough becomes more frequent and 
painful, and the general aspect of the patient is that of one suffering from 
an affection of a severe type. 



DISEASES OF THE BRONCHI AND LUNGS. 697 

Onset. — The onset of broncho-pneumonia varies according as the dis- 
ease is primary or secondary. In the primary form the symptoms may 
be mistaken for a lobar pneumonia. They begin abruptly with a chill or 
convulsion, with a rapid rise in the temperature, which is more constant 
than in the secondary forms. The signs are more local in character and 
the disease may be masked by the intensity of the cerebral symptoms. 

The secondary form begins as an inflammation of the bronchioles, and 
is not to be distinguished from a capillary bronchitis, which is essentially 
the same disease. The onset is rarely sudden, and there is no chill as a 
rule. It is frequently associated with one of the infectious fevers, occur- 
ring during the course of the disease or in early convalescence, or as a 
result of an inhalation of foreign bodies. The child appears fretful and 
restless. The temperature rises and is very variable. There is cough, 
dyspnoea, and rapid respiration. The physical signs are often limited to 
scattered localized areas of fine and medium moist rales, and sometimes 
sonorous and sibilant rales ; dulness may or may not be present in this 
early stage. 

Temperature. — The temperature in broncho-pneumonia varies greatly, 
according to the extent and severity of the lesions. Corresponding to the 
intensity of the pneumonic onset, or to the especial disease which it com- 
plicates, the temperature rises rapidly or slowly and insidiously. The 
most common course in mild cases with gradual onset and terminating in 
recovery is for the temperature to rise gradually to 39.4° or 40° C. (103° 
or 104° F.), then to have a morning remission of three or four degrees 
for a number of days, and finally to fall irregularly by lysis. A crisis is 
very rare in broncho-pneumonia, but sometimes occurs in the primary 
form of the disease. Although the remissions in the temperature during 
the active stage of the disease are often quite marked, yet, as a rule, the 
temperature does not at this time fall to the normal. This is of service 
in differentiating certain cases of broncho-pneumonia, as well as of lobar 
pneumonia, from malaria. In the more severe and unfavorable cases the 
temperature becomes more and more elevated, even reaching as high as 
41.6° C. (107° F.). Occasionally the temperature is reversed, the highest 
point being reached in the morning. This is rare, and is of no especial 
significance. When the temperature instead of remitting remains high 
and steadily rises, the disease, as a rule, soon terminates fatally. Instead 
of the continued high temperature which occurs so often in fatal cases, 
a low temperature of only a few degrees above normal is sometimes met 
with, usually when the vitality is low and the power of reaction slight. 
The duration of the heightened temperature is very variable, and may- 
last for a number of clays or for weeks without the necessary result of 
the grave lesions of a more chronic process. 

Pulse and Respiration. — The pulse and respiration, although increased 
in frequency, vary according to the severity of the disease and also accord- 
ing to the degree of nervous excitement. This latter is a very important 



698 PEDIATRICS. 

element to be considered in determining the gravity of their rate. The 
pulse is at times very rapid, 160 to 180, and even higher ; it usually varies 
from 130 to 150 or 160 ; although regular and full at first, it becomes weak 
and sometimes irregular as the disease progresses, and is very apt to remain 
rapid even after the temperature has declined and convalescence has been 
established. The respirations may be quickened by an unusually high 
temperature, but depend mostly on the extent of the involvement of the 
alveoli. They vary from 50 to 80, but they may be even higher, and are 
accompanied by dilatation of the alse nasi. 

The respiration often shows a pause after inspiration instead of after 
expiration, as occurs in normal .respiration, and is usually accompanied by 
an expiratory moan. This sign, however, is not characteristic of broncho- 
pneumonia, as it may occur in lobar pneumonia and in various affections 
in which the circulation is interfered with and respiration is painful. In 
like manner the dilatation of the alse nasi may occur in any disease accom- 
panied by a heightened temperature and nervous excitement. Temporary 
exacerbations and changes in the rhythm of respiration are quite common 
in broncho-pneumonia, and in some cases a Cheyne-Stokes type of res- 
piration has been noticed. This sign is usually one of grave import. Re- 
cession of the epigastrium and of the intercostal spaces commonly occurs 
in broncho-pneumonia, and varies according to the severity of the pulmo- 
nary lesions. In infants painful respiration is shown by a frown rather 
than by crying, while in young children it is shown by their whimpering 
and suppressed cries. 

Cough. — A frequent, short, hacking, and painful cough is a constant 
symptom from the beginning of the disease, and even after resolution has 
taken place this may continue for a long period. Infants and young chil- 
dren, even up to the age of seven or eight years, have often not learned 
to expectorate, so that we cannot, as in adults, judge of the character of 
the sputum. 

Gastro-Enteric Symptoms. — Vomiting is at times met with, and diar- 
rhoea is not uncommon. In certain cases disturbance of the gastro-enteric 
tract is present from the very beginning, and the intestinal disease is ap- 
parently as prominent a feature of the attack as the pulmonary symptoms. 
As the attack progresses the child loses much in weight, the face often 
looks pinched, and at times during the height of the disease there is a 
certain amount of delirium, which in combination with other grave 
symptoms, such as uncontrollable diarrhoea and a depressed temperature, 
is a serious symptom. 

Cyanosis and Dyspnoea. — A symptom which occurs quite commonly 
in broncho-pneumonia is cyanosis. This may not only arise from the 
interference with the oxygenation of the blood from the lesions involving 
the air-vesicles, but may also be produced by a temporary atelectasis of 
certain portions of the lungs. The cyanosis is often accompanied by 
attacks of dyspnoea. When these symptoms result from atelectasis, the 



DISEASES OF THE BRONCHI AND LUNGS. 699 

temperature, as a rule, does not rise, but may even be somewhat reduced, 
and areas of dulness may be detected on percussion. During these 
paroxysms the skin is often cold and moist. When the cause of the 
atelectasis, whether it be obstruction by plugs of mucus or pus or tem- 
porary exhaustion of the contractile powers of certain portions of the 
lungs, has been removed, the cyanosis and dyspnoea pass away and the 
general symptoms improve. These symptoms may arise at various 
periods during the course of broncho-pneumonia, and unless the atelec- 
tasis passes off within a few days a fatal issue is very apt to result. 

In cases which recover, resolution takes place slowly and the lung 
gradually returns to the normal condition. Great weakness and pros- 
tration often last for a long time. Relapses are quite common. 

Blood. — A leucocytosis is generally present if the broncho-pneumonia 
is due to the pneumococcus or to mixed infections. When the process is 
excited by the bacillus of influenza or the bacillus of Friedlander alone, 
the white blood count is either normal or only slightly elevated. 

Physical Signs. — The physical signs of broncho-pneumonia are almost 
entirely those of the accompanying bronchitis, but in typical cases they 
correspond to the various pathological lesions which have been described. 
According as larger or smaller areas of the lung are involved, corre- 
sponding areas of dulness on percussion may be found, provided these 
areas are sufficiently extensive not to be masked by other resonant por- 
tions of the lungs. They can, as a rule, be detected best by very light 
percussion. These areas of dulness are usually bilateral and of some- 
what varied extent, although, as has already been stated, an entire lobe 
may in rare instances be sufficiently involved by the broncho-pneumonic 
process to produce very extensive areas of dulness. Over the area of 
dulness bronchial respiration, and in some cases increased vocal resonance 
and fremitus, may be found. On auscultation moist rales of all grades may 
be heard all over the lungs, or, as is more usual, in circumscribed areas. 

Well-marked physical signs, especially dulness on percussion, are 
sometimes found at the bases of both lungs behind, and also between the 
scapulae and the vertebral column. The earliest changes, however, in 
percussion and auscultation are sometimes first detected in the highest 
part of the axilla. These signs of consolidation are rarely found in the 
early days of the disease, as at this time signs of bronchitis are usually 
all that can be detected. 

The absence of demonstrable areas of dulness is, however, so very 
common that it is almost characteristic. This may be due to the fact that 
the consolidation is deep-seated or in such small areas and so interspersed 
with uninvolved lung-tissue that although superficial in distribution it 
causes no perceptible change in the percussion-note. The physical signs 
are markedly modified when atelectasis or emphysema is present. 

Terminations and Complications. — Resolution. — If the course of the 
disease is favorable, the pathological process in the areas of consolida- 



700 PEDIATRICS. 

tion terminates in resolution, which is often more rapid in the individual 
areas than in lobar pneumonia, but may be delayed for several days or 
weeks as in the latter affection. 

Suppuration. — Resolution by suppuration is rare in the more common 
forms of primary and secondary broncho-pneumonias, and is limited 
almost entirely to cases of inhalation or deglutition broncho-pneumonias, 
in which it is very frequent. Under the same conditions gangrene of the 
lung may develop. 

Chronic Fibroid Changes. — These will be described separately on 
page 705. 

Tuberculosis. — Cases of broncho-pneumonia with delayed resolution 
show a special susceptibility to infection by the tubercle bacillus. This 
complication will be found more fully described on page 394. 

Diagnosis. — The diagnosis of broncho-pneumonia should first be made 
from the bronchitis which ordinarily accompanies it. This has already 
been sufficiently referred to in speaking of the diagnosis of bronchitis. 

The differential diagnosis between the non-tubercular and the tuber- 
cular forms of broncho-pneumonia is important, but can rarely be made 
in the early stages of the disease, as the lesions are the same, and a bac- 
teriological examination of the sputum in these cases can seldom be 
obtained. 

The disease which should be especially considered in making the 
diagnosis of broncho-pneumonia is lobar pneumonia. The differential 
diagnosis has been given in connection with pneumococcus lobar pneu- 
monia on page 683. 

Prognosis. — Age is a very important factor in the prognosis of bron- 
cho-pneumonia. As shown by Morrill a large majority of the fatal cases 
occurs in the first two years of life. Broncho-pneumonia causes more 
deaths in children than are due directly to the fevers, and is the most 
serious complication of the contagious diseases. The prognosis varies 
according to the disease in the course of which it arises. It is most grave 
when it occurs in pertussis, especially in infants, and the younger the 
child the more fatal the disease. Next to pertussis, the gravity of the 
prognosis is greatest in measles and in diphtheria. When it occurs in 
such diseases as rhachitis and tuberculosis, or when the individual has 
not been well cared for, the prognosis is also very unfavorable. The 
prognosis is almost fatal in cases in which the bacillus of Friedlander 
is the exciting cause, and in other forms when complicated with tuber- 
culosis. 

I have already referred to the temperature as a prognostic sign in 
broncho-pneumonia. According to Holt's observations, the highest mor- 
tality occurs among the cases of shortest duration, and the disease is 
universally fatal when its duration is shorter than four days. After this 
early period of danger is passed the prognosis becomes much more favor- 
able, the lowest death-rate in Holt's cases being met with in cases termi- 



DISEASES OF THE BRONCHI AND LUNGS. 701 

nating in from eight to fourteen days. When the disease lasts for more 
than two weeks the chances of recovery are lessened every day that the 
temperature remains raised. The cases in which there is a very high 
temperature, 41.1° C. (106° F.), are usually fatal. When the disease is 
protracted, death generally occurs from exhaustion. 

Treatment. — The treatment of broncho-pneumonia is that of the special 
disease to which it is secondary, and is for the most part symptomatic. The 
strength should be carefully supported from the time that the disease is 
first detected until convalescence has been completely established. The 
patient should be intelligently nursed, as the nursing is the most important 
part of the treatment. The atmosphere of the room should be equable, 
the temperature from 20° to 21.1° C. (6S° to 70° F.), and especial atten- 
tion should be paid to the ventilation. The heat and ventilation obtained 
from an open Avood-fire are especially valuable. 

As few drugs as possible should be given, since there is no remedy 
Avhich will cut short the disease, and most of the drugs commonly used 
in the treatment of pulmonary affections are, as a rule, of more harm 
than benefit in broncho-pneumonia. The vitality of infants and young 
children is so easily lessened by a disease so severe as broncho-pneumonia 
that the respiratory power is likewise quickly diminished, and we should 
avoid, except when they are especially needed, such drugs as opium. 
Ipecac in minute doses seems to facilitate the removal of the mucus. 
During severe paroxysms an atmosphere of steam or the administration 
of oxygen is indicated, according as the symptoms seem to be produced 
by a tenacious exudate or by unaerated lung-tissue. Oxygen is also of 
benefit in relieving the cyanosis and dyspnoea throughout the disease, and 
may be given for ten minutes every one or two hours. In cases in which 
cyanosis and dyspnoea are urgent, if the symptoms depend upon mechanical 
obstruction with its resulting atelectasis, an emetic is occasionally de- 
manded. In some cases, also, when much exhaustion arises from inces- 
sant coughing, small doses of tinctura opii camphorata may be used with 
caution, and discontinued as soon as possible. When the urgent symp- 
toms are caused by the heightened temperature, much relief can be 
obtained by means of a bath given at a temperature of 32.2° C. (90° F.). 
This may be followed by the warm wet pack, which can often be con- 
tinued with benefit for several hours, and is especially beneficial in pro- 
ducing deep inspirations by which dependent portions of the lung are 
aerated. In some cases reaction does not take place, and signs of ex- 
haustion follow the bath. Under these circumstances phenacetine may be 
substituted for the bath. The dose should be 0.06 to 0.12 gramme (1 to 
2 grains), guarded with five or ten minims of brandy. This will often 
reduce the temperature two or three degrees, and in some cases it will 
remain down for five or ten hours, during which period the infant shows 
a marked diminution of its nervous symptoms. The position of the child 
should be changed from time to time, as there is a tendency for the in- 



702 



PEDIATRICS. 



Fig. 148. 



flammatory exudate to collect in the lower and back portions of the lungs. 
The administration of food at regular intervals is very important, and 
should be carried out rigorously. 

The chief part of the diet, if possible, should be milk, supplemented 
with broths, the food being regulated on the general principles governing 
feeding at different ages. Although vomiting may occur in certain cases, 

as a rule, if the diet is carefully regu- 
lated and the milk given once in two 
hours with stimulants adapted to the 
condition of the especial case, an over- 
sensitive condition of the stomach is 
seldom a serious obstacle to the treat- 
ment. 

As the disease progresses it is 
quite common for the infants to refuse 
their food. Feeding by means of the 
stomach-tube, preferably through the 
mouth, then becomes imperative. 

The paroxysmal attacks of cyanosis 
and dyspnoea may be caused by a 
weak heart. In these cases the ad- 
ministration of brandy and digitalis, 
the latter in the form either of tinc- 
ture or of infusion, for a few days, 
until the cardiac condition has im- 
proved, is indicated. Strychnine and 
nitroglycerin may also be used, the former being considered especially 
important. Appropriate doses of alcohol for children of different ages is 
given on page 456, and those of the other more important cardiac stimu- 
lants on page 470. 

When convalescence has been established the children are often left 
in a very weak condition, and special attention should then be paid to the 
nursing and to the general hygiene. The restoration of strength should 
be aided by means of tonics, and, if possible, the child should be removed 
to an equable, warm climate. 




Acute broncho-pneumonia. Female, 4% 
years old. The black circles indicate areas 
of consolidated lung-tissue ; the black spots 
indicate rales. 



Fig. 148 represents a girl, four and one-half years old, in whom the physical ex- 
amination showed very marked lesions of broncho-pneumonia. 

There was no tubercular history in her family. She had scarlet fever when she 
was one year old, measles when she was one and a half, pertussis and varicella when 
she was three, and bronchitis when she was three and a half years old. She had 
otherwise always been well, when she began to complain of headache and pain in her 
chest. On the ninth day of the attack she vomited, and two days later began to cough 
and to be rather somnolent. Her bowels were regular. On physical examination the 
child was found to be rhachitic, as shown by a rosary, enlarged epiphyses of the wrists 
and ankles, and marked bowing of the legs. On entering the hospital her pulse was 
160, her respirations 60, and her temperature 39.4° C. (103° F.) in the morning and 



DISEASES OF THE BRONCHI AND LUNGS. 703 

40° C. (104° F.) in the evening. She seemed very sick, had considerable cough, but no 
expectoration ; there was some dyspnoea, and at times she was somewhat cyanotic. 
On examining the chest the percussion was found to be resonant, but throughout both 
lungs there were moist rales. Nothing abnormal was detected on examining the heart 
and abdomen. She was treated with milk and brandy. 

On the following day she was in about the same condition, and her pulse, respira- 
tions, and temperature were the same as when she entered the hospital. In certain 
circumscribed areas in both backs slight dulness was detected on percussion, with 
moist rales around the edges of these areas. 

On the third day the pulse had fallen to 136, the respirations to 40, and the tem- 
perature to 38.3° C. (101° F.). On the ninth day of the disease the pulse was 
stronger and the child's condition was very much improved. The dyspnoea had dis- 
appeared almost entirely, there was no cyanosis, and she was more comfortable. The 
front of the chest showed the resonance on percussion to be normal, and no abnormal 
sounds on auscultation. On examining the back certain circumscribed areas of 
dulness were found, the borders of which are marked in black. One of these areas 
was between the edge of the scapula and the vertebral column, another was at the 
right base in the posterior axillary region, and another at the left base just below the 
angle of the scapula. Over these areas of dulness bronchial respiration was heard. 
Just outside of the areas of dulness moist rales of various sizes, which are indicated 
by black dots, could be heard in limited areas. The physical signs corresponded in 
their distribution to the areas in which the lesions of this disease are usually detected 
on physical examination. 

On the fourteenth day the child was found to have much improved. During the 
following ten days the abnormal signs in the chest disappeared, but the pulse, res- 
pirations, and temperature did not become permanently normal for a week later. The 
child, after remaining weak and debilitated for some time, was finally discharged 
from the hospital in good condition. The temperature, pulse, and respirations declined 
by lysis on the ninth day of the disease and reached the normal on the twelfth day. 

This case apparently arose in the course of a slight bronchitis occur- 
ring in a rhachitic child. The prognosis of broncho-pneumonia in rha- 
chitis is usually unfavorable, but in this case the child possessed sufficient 
vitality not to succumb to the disease. 

The following case illustrates the gravity of broncho-pneumonia when 
it occurs in a rhachitic child. 

The child was two years and one month old. Its mother died of pulmonary 
tuberculosis. It had bronchitis when it was one year old. and the cough continued for 
three months. One week before entering the hospital it was attacked with a severe 
cough, and began to lose in weight and to have diarrhoea. A physical examination 
showed that it was a case of marked rhachitis. The breathing was rapid and labored, 
there was considerable cyanosis, and the child was dull and somnolent. Patches of 
dulness were found in various parts of the lungs, with moist rales of different sizes. 
The pulse varied from 140 to 150, the respirations from 80 to 90, and the temperature 
from 38.8° to 40° C. (102° to 104° F.). The symptoms increased in severity, the 
child grew weaker, and on the second day after it entered the hospital it died suddenly. 

When broncho-pneumonia attacks a child with such marked rhachitis 
as was shown in this case, a fatal issue almost always results. 

The next case was that of a girl, two years old. who previously had been well and 
strong until she was attacked with measles. There was no tubercular history in the 



704 



PEDIATRICS. 



family. On the fifth day of the measles her temperature was 39.8° C. (103.7° P.), the 
pulse was 120, and the respirations were 62. An examination of the chest showed the 
heart to be normal, the percussion normal, and the respiration harsh, with numerous 
fine and coarse moist rales throughout both lungs. Nothing else abnormal was detected. 
The temperature fell by a sharp crisis on the sixth day and remained normal for 
two days, during which the efflorescence rapidly faded and the patient seemed better, 

though she occasionally had a harsh 
CHART 31. cough. On the ninth and tenth days 

she had a slight rise of temperature, 
but there were no marked symptoms 
until the eleventh day, when the tem- 
perature rose to 40° C. (104° P.), the 
pulse to 160, and the respirations to 
50. She was very restless, and had 
considerable dyspnoea. She was pal- 
lid and sometimes slightly cyanotic. 
On physical examination there was 
found diminished resonance over an 
area in the lower part of the left back. 
Over this area the breathing was 
bronchial, and there was also a num- 
ber of moist rales. On the right 
side of the thorax, especially at the 
base of the lung, there were numer- 
ous coarse moist rales and harsh res- 
piration, but no dulness. Chart 31 
shows the course of the temperature, 
pulse, and respiration during the 
twelve days of the broncho-pneu- 
monia. The pulse continued to be 
rapid and the respirations to be some- 
what raised for some days after the 
temperature became normal. The 
abnormal signs in the chest disap- 
peared, and the child made a rapid 
recovery. 

This case illustrates the rapid 
development of a broncho-pneumonia 
during an attack of measles, occur- 
ring after the temperature produced 
by measles had fallen to the normal 
and while the efflorescence was dis- 
appearing. The physical signs showed the presence of small areas of consolidation in 
the left lung, and the usual diffuse bronchitis throughout the right lung and parts of 
the left lunar. 





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Broncho-pneumonia following crisis of measles. 
2 years old. 



Child, 



Chronic Broncho -Pneumonia. — In a certain number of cases, after a 
child has had an attack of acute broncho-pneumonia the physical signs of 
consolidation may persist, although apparent recovery has taken place so 
far as the general symptoms are concerned. When this occurs the fever 
may return after a variable period, and the child, after having become 
still more emaciated, may die after a number of months of exhaustion. 



DISEASES OF THE BRONCHI AND LUNGS. 705 

These cases are very apt to be associated with a tubercular broncho- 
pneumonia which may eventually heal by the production of fibroid cica- 
trices, but the most common termination of these cases is in acute general 
miliary tuberculosis. Instead of this fatal issue, the child, as has been 
shown by Delafield, may be left with a chronic form of the disease, which 
may last for many years and be accompanied by symptoms of cough, 
dyspnoea, and at times periods of fever. Broncho-pneumonia of a sub- 
acute or of a chronic type is so apt to develop in the lungs of young children 
during the course of any disease of a prolonged nature that frequent 
examinations of the lungs should be made, in order that the insidious 
development of these pulmonary lesions may not be overlooked. 

Treatment. — The treatment of these chronic cases of broncho-pneu- 
monia is essentially symptomatic and climatic. The child should be 
taken to a warm, dry climate of high altitude, where it can live in the 
open air and where it will not be subjected to frequent atmospheric 
changes. 

HYPOSTATIC PNEUMONIA. 

Hypostatic pneumonia is an extreme degree of passive congestion 
which occurs in the course of many long-continued diseases, such as 
typhoid fever. The dependent portions of the lungs become engorged 
with blood and the alveoli partially filled with accumulated alveolar cells, 
so that the condition resembles a consolidation. It occurs especially in 
patients whose vitality has been greatly lowered by a prolonged illness, 
and who are kept too long in one position without being turned. 

The physical signs are those of slight dulness on percussion, generally 
at the base of the posterior lobes, diminished tactile fremitus, and feeble 
respirations and voice-sounds. Moist rales, generally bilateral, are heard 
over the areas of dulness, but fever, pain, and cough are absent. 

The condition is recognized by the presence of the primary disease and 
by the gradual development of the physical signs without the characteristic 
features of pneumonia or pleurisy. It may, however, give no evidence 
of its presence during life, and may be discovered only at the autopsy. 

Treatment. — The treatment is chiefly prophylactic during the course 
of the primary disease. The nurse should see that the child is not 
allowed to lie in one position for more than two hours. The condition 
calls for active stimulation. 

ATELECTASIS. 

Atelectasis is a collapsed and unaerated condition of the air-vesicles. 
It may be congenital or acquired. 

Congenital Atelectasis. — Congenital atelectasis arises because the 
infant has not sufficient general vitality and respiratory power at birth to 
inflate fully all parts of its lungs. There may be an obstruction by 
mucus. There are in all these cases areas of uninflated pulmonary 
vesicles of varying extent. These vesicles at the post-mortem exami- 

45 



706 PEDIATRICS. 

nation can easily be artificially distended and then cannot be distinguished 
from those which have been normally inflated. 

Symptoms. — The symptoms of congenital atelectasis are cyanosis, 
dyspnoea, rapid respiration, rapid, feeble, and often intermittent pulse, a 
temperature usually lowered, and dulness on percussion with lessened 
respiration over the area of atelectasis. These are the typical physical 
signs, but in many cases some or all of these signs are absent and the 
condition is detected only at the post-mortem examination. 

Acquired Atelectasis. — Acquired atelectasis is a symptom of a num- 
ber of diseases, and occurs especially in severe cases of bronchitis in 
which the smaller bronchi are involved, also in broncho-pneumonia and 
in pertussis. Acquired atelectasis undetected during life is frequently 
found at the post-mortem examination of infants and young children 
dying of almost any disease. 

Prognosis. — The prognosis in these cases varies according to the ex- 
tent of the pulmonary tissue involved and the vitality of the infant. As 
a rule, the prognosis is very unfavorable. 

Treatment. — The treatment of atelectasis is to stimulate the infant, and 
to endeavor to raise its temperature by means of a warm pack. In a num- 
ber of cases I have found the administration of small quantities of oxygen 
to be of benefit. Artificial inflation of the air-vesicles has not proved to 
be an especially valuable form of treatment. Many cases of atelectasis 
may be avoided if the physician appreciates the importance of making an 
infant, in the first few minutes after birth, thoroughly expand its lungs by 
vigorous crying. 

EMPHYSEMA. 

Emphysema is an over-distention of the alveoli and infundibula of the 
lungs. It is always a secondary process. Various descriptive terms have 
been used to denote differences in the type of the disease. 

Compensatory emphysema consists in a dilatation of the alveoli in 
certain portions of the lung as a result of obliteration of the function of 
other parts by consolidation, adhesions, or pressure of deformed bones. 
This condition is likely to occur in connection with pneumonia, tuber- 
culosis, chronic adhesive pleurisy, or rhachitis. 

Obstructive emphysema represents the same pathological lesions, but 
the cause lies in some obstruction to expiration, as in stenosis of the 
larynx, asthma, and pertussis. 

Interstitial emphysema occurs rarely as a result of a rupture of the 
walls of the alveoli, by which the air works through the interstitial tissue 
of the lung into the subcutaneous tissue. 

Symptoms. — Hyperresonance on percussion, feeble breathing, pro- 
longed expiration, diminution in tactile fremitus and voice-sounds are the 
physical signs of emphysema. The normal area of cardiac dulness may 
be much diminished by the overlapping emphysematous lung ; in the 
same way the upper border of the liver dulness may be considerably 



DISEASES OF THE PLEURA. 707 

lowered. The symptoms are those of the disease in which the emphy- 
sema occurs. 

Treatment. — The treatment should be adapted to the underlying con- 
dition. 

GANGRENE AND ABSCESS OF THE LUNG. 

Gangrene and abscess of the lungs are represented essentially by the 
same clinical symptoms, and may occur in connection with lobar or 
broncho-pneumonias. They are caused by the action of suppurative and 
putrefactive bacteria which invade the affected portions of the lung with 
the production of small or large abscesses. 

Gangrene is diagnosticated chiefly by the presence of putrid, purulent 
sputum containing elastic fibres. It is to be distinguished from fetid 
bronchitis, which does not contain the elastic fibres of the lung-tissue. 

The rupture of an empyema into a bronchus, with the resulting ex- 
pectoration of purulent sputum, simulates the condition of abscess, but 
the diagnosis should be made by the physical signs of empyema. The 
treatment is that of the primary disease. 



DISEASES OF THE PLEURA. 

Inflammations of the pleura may be primary or secondary, acute or 
chronic, and with or without an exudation. 

ACUTE PLEURISY. 

Etiology. — Acute pleurisy, either with a simple exudation of fibrin or 
accompanied by fluid, is not infrequent in children in the winter and 
early spring. 

Primary forms occur, but are very rare, and are attributed to exposure 
to cold or to injury, as from penetrating wounds and fractured ribs. 

Secondary forms are the rule ; they occur by direct extension in con- 
nection with lobar pneumonia, broncho-pneumonia, tuberculosis of the 
lungs, pulmonary embolism, pericarditis, peritonitis, or some neighboring 
local inflammation. They may also be caused by metastatic infections 
from distant inflammatory processes, by means of the blood-vessels or 
lymphatics, or in the course of acute infectious fevers. Pleurisy may also 
occasionally be associated with nephritis and syphilis. 

The bacteriology of inflammations of the pleura includes many varie- 
ties of organisms. The pneumococcus is found in the great majority of 
cases of pleurisy in early life and is generally accompanied by a purulent 
exudation ; these cases are apt to arise in connection with pneumonia and 
run a favorable course. The streptococcus pyogenes causes a much more 
serious, and often fatal, purulent infection, but is less common in children 
than in adults. 

Tubercular pleurisy is rare in infancy, but occurs more frequently in 
the later years of childhood. Eichhorst has shown in one series of serous 



708 PEDIATRICS. 

exudations that nearly sixty-five per cent, of the cases were tubercular, 
but the pneumococcus, diplococcus, and staphylococcus are sometimes 
found in these non-purulent exudations. The staphylococcus, gono- 
coccus, Friedlander's bacillus, colon bacillus, and typhoid bacillus have 
occasionally been cultivated from the purulent exudations. 

In acute inflammations of the pleurae we can make a clinical dis- 
tinction between three types of the disease, based upon differences in 
the pathological lesions : (a) acute dry or plastic pleurisy, (b) acute 
pleurisy with sero-fibrinous exudation, and (c) acute pleurisy with puru- 
lent exudation (empyema). 

Acute Dry or Plastic Pleurisy. — Pathology. — The pleura is injected 
and without lustre. At first it is covered with a thin layer of lymph, 
which becomes opaque and thickened by the deposition of fibrin and 
leucocytes. The sub-pleural fibrous tissue is also thickened by the exuda- 
tion of serum and by cellular infiltration. The roughened surfaces of the 
visceral and parietal layers may adhere, forming loose connections which 
may subsequently undergo organization without producing an exudation 
and end in a chronic adhesive pleurisy. The areas of inflamed pleura 
may be large or small and diffusely located. They may rarely occur at 
the apices of the lungs in connection with an early tubercular process. 
On the other hand, they may be limited to the base and give rise to 
diaphragmatic pleurisy. 

The term pleuro-pneumonia has been applied to those cases of dry 
pleurisy in which there has been an excessive exudation and deposition 
of pus-cells in the layer of fibrin without the formation of free fluid in 
the pleural cavity. 

Symptoms. — Although localized areas characterized by the production 
of fibrin are quite frequently found at the post-mortem examination, the 
diagnosis of this form of disease in infants and in young children is not 
often made during life. The symptoms are of acute onset, characterized 
by a sharp pain or stitch in the side, slight fever, and a short, dry cough. 
The pain is usually referred to the lower part of the axilla, where the 
largest excursions of the two layers of the pleura take place in the act 
of breathing, or to the abdomen. On auscultation a friction-rub may be 
heard at the site of the pain or remote from it. In infants and young 
children, however, friction-sounds and pleuritic pain are much less pro- 
nounced than in adults, and a pleurisy is often not even suspected until 
the advent of the exudation. Probably in the great majority of cases of 
dry pleurisy in early life the condition is secondary to lobar or broncho- 
pneumonia, and its signs and symptoms may be masked by those of. the 
primary disease. 

Acute Pleurisy with Sero-Fibrinous Exudation. — Pathology. — The 
pathological exudate of a dry or plastic pleurisy may be directly absorbed 
or the inflammation may result in an exudation of serum and fibrin into 
the pleural cavities. 



DISEASES OF THE PLEURA. 709 

The fluid is of a clear, pale-yellow color, coagulates spontaneously, 
and contains flocculi of fibrin and a few leucocytes and endothelial cells. 
The amount of fibrin varies, and, according as it is small or large in 
relation to the serum, we speak of the exudate as serofibrinous or 
fibrino-serous. A greater proportion of fibrin is likely to be present in 
the exudation in children than in adults. 

The quantity of fluid may be small and encysted, and accompanied 
by areas of atelectasis in the adjacent lung, or it may fill the Avhole cavity, 
compressing the lung against the spine, and thus practically depriving it of 
its functions. In a similar manner when the exudation is on the right side 
the liver is depressed. Displacements of the heart and pericardium very 
commonly occur when the exudation is either on the right or the left side. 

Symptoms. — The onset of acute pleurisy with serous exudation is in 
many cases violent, and attended by a high temperature, increased 
respirations, rapid pulse, restlessness, and even pain, which in young 
children is usually referred to the abdomen. In infants and in young 
children convulsions are quite common, while in older children the 
symptoms are more like those which occur in adults. There is a short, 
painful cough, with loss of appetite, and frequently vomiting and diarrhoea. 

The white blood count is rarely increased in serous exudations, except 
in the febrile stages, and even then is not often over thirteen thousand. 
Uncomplicated cases of tubercular pleurisy probably never have a leuco- 
cytosis (Cabot). 

These early symptoms are usually followed in two or three days by 
an exudation and by a decided lessening of the pain and dyspnoea. At 
the same time the temperature begins to have a decided morning re- 
mission. When the exudation is large, the children lie more comfortably 
on the affected side, and when they are nursing they nurse most easily 
from the right breast if the left pleura is affected, and from the left breast 
if the right pleura is affected. After the serous exudation has remained 
for a few days it ordinarily begins to lessen in amount, absorption takes 
place, and by the end of a week or ten days it is entirely absorbed and 
the child recovers. In other cases it becomes chronic unless its absorption 
is furthered by aspiration. 

Physical Signs. — The physical signs of fluid in the pleural cavity 
differ in certain respects from the usual signs in adults. 

Inspection. — On inspection we find diminished movement of the 
affected side on inspiration, and if the fluid is large in amount, a decided 
bulging. The impulse of the apex beat is often displaced, depending 
on the quantity of the exudation and the side affected. The displace- 
ment of the heart is most marked in left-sided effusions, in which the 
impulse may be seen in the third and fourth right intercostal spaces, and 
sometimes as far out as the mammillary line. In right-sicled effusions the 
degree of displacement is less, but the impulse may be seen in the fourth 
interspace and between the mammillary and midaxillary lines. 



710 PEDIATRICS. 

Palpation. — By palpation the intensity of the apex beat and the 
amount of displacement of the heart and of the liver (in right-sided 
affections) may be determined. The information to be obtained by tactile 
fremitus is not of much value in infancy and early childhood ; its diminu- 
tion is not marked, and occasionally it is quite distinct over an exudation. 
Thus one of the most valuable of differential signs from consolidation 
fails in the doubtful cases in children. 

Percussion. — The percussion-note varies from slight dulness to flat- 
ness, according to the quantity of the fluid, and there is a sense of in- 
creased resistance to the fingers. Above this level of dulness the note 
is normal or tympanitic (Skoda 1 s resonance), and may be most pronounced 
in front below the clavicles. On the right side the dulness may be con- 
tinuous with that of the liver, on the left it may obliterate the semilunar 
space of Traube. 

The upper border of a fluid exudate has certain peculiar character- 
istics, as shown by Ellis and Garland, if not complicated by pleural adhe- 
sions, and is often of aid in the differential diagnosis from consolidation 
of the lung. When the fluid is small in amount it can usually first be 
detected in the back. In these small exudations the upper border of 
dulness begins at the vertebral column, extends outward horizontally for 
a distance which varies according to the size of the exudation, and drops 
in the neighborhood of the posterior axillary line, by a curve more or less 
abrupt, to the base of the thorax. As the fluid increases in size the line 
of dulness drops more anteriorly. When it is moderate, the lower half 
of the pleura only being filled, the upper border of the area of dulness is 
found to extend at first outward and then upward over the angle of the 
scapula, reaching its highest point in the axillary region. The line may 
then drop abruptly from the upper axilla to the base of the thorax near 
the apex of the heart or to the corresponding point on the right side. This 
line, which has been called the "letter S curve," is characterized by 
having its highest point in the axillary line. When the quantity of fluid 
is still larger and exceeds a certain amount, the " letter S curve" is 
obliterated, and the resonance over the compressed lung becomes less 
marked. This curve can only be determined by very light percussion. 

If the line of dulness is altered by a change in position of the body, 
it is a positive sign of fluid. An encysted exudation or a large amount 
of fluid will not give this sign. 

The displacement of the heart is a most valuable indication of effusion 
. in young children, and with careful, light percussion the gradual increase 
and decrease of the effusion, when it is of any great extent, can be de- 
termined by the variations in the position of the heart. The physio- 
logical dulness of the heart which has been described as occurring in 
early childhood (page 90) under the lower third of the sternum, becomes 
much more marked when the heart is displaced. 

Auscultation. — The sounds obtained by auscultation are variable, and 



DISEASES OF THE PLEURA. 711 

in some respects are very different from those which are heard over a 
pleural exudation in an adult. Bronchial breathing is the rule rather 
than the exception. It is, however, less intense and more distant than 
that which we ordinarily hear over an area of consolidation. Vocal reso- 
nance, moreover, is generally increased (bronchophony), and is some- 
times as pronounced as in pneumonia. Occasionally it will give the 
same nasal quality as over a consolidation. Friction-sounds above the 
level of the fluid, or after absorption, are rare in early life. Moist rales 
are sometimes heard over an exudation, and are probably of bronchial 
origin. Even friction-sounds are sometimes said to be heard over the 
fluid, but are probably transmitted from points above the level of the 
exudation. 

Diagnosis. — The principal physical signs of pleural effusion in infancy 
and early childhood are flatness which does not correspond to the ana- 
tomical divisions of the lobes of the lung, bronchial breathing, varying in 
intensity, bronchophony, displacement of the heart, and changes in the 
outline of dulness on shifting the position of the body. The differential 
diagnosis can best be described in connection with purulent exudations 
(page 713). 

Prognosis. — The prognosis of a serous effusion, as a rule, is very favor- 
able in infants and in young children unless the streptococcus or one of 
the more virulent forms of the pyogenic cocci is present, or unless the 
disease is secondary to tuberculosis elsewhere and is caused by the tubercle 
bacillus. If the serous exudation tends to become purulent, the prognosis 
is not so good, but still, provided appropriate treatment is carried out, it 
is favorable. If, as in rare cases, the pleuritic exudation occurs on both 
sides, the prognosis becomes grave. The possibility of the presence of 
the tubercle bacillus should be considered in these latter cases. 

I had in my service at the Boston City Hospital a boy, thirteen years old, who was 
attacked with pleurisy and a serous exudation on the left side with displacement of the 
heart to the right. After one aspiration the fluid was quickly absorbed, but three 
weeks later he was attacked with pleurisy on the right side, followed by an exudation 
and displacement of the heart to the left. This effusion was absorbed without aspira- 
tion, and the boy was discharged from the hospital well and strong, with both lungs 
apparently in a normal condition. 

When the effusion is very large and the heart is much displaced, there 
is always the danger of a fatal issue from asphyxia, and the prognosis de- 
pends upon whether the exudation can be controlled by aspiration and 
the heart thus be kept in normal position. The following case illustrates 
the danger which may arise when these large quantities of fluid are 
accompanied by displacement of the heart. 

A boy, four or five years old, entered the hospital with a large exudation in the 
left chest. The heart was displaced to the right and upward as far as the second 
interspace to the right of the sternum. He was cyanotic and gasping. On aspirating 



712 PEDIATRICS. 

the chest and removing a large quantity of fluid, the heart reassumed its normal posi- 
tion under the sternum. On the following night the boy died suddenly, the fluid 
having rapidly reaccumulated and again displaced the heart. 

Cases of this kind should warn us that a pleuritic exudation of any 
extent in a young child should be watched carefully, and that aspiration 
should be performed when there is indication of an increase in the intra- 
thoracic pressure. 

When the pleurisy is secondary to other diseases, such as rheumatism 
and scarlet fever, the prognosis is not so favorable ; the fluid is not apt to 
be absorbed so readily, and is more likely to become purulent. The 
prognosis is also rendered more unfavorable in these cases by the pro- 
longed pressure upon the lung, with its corresponding ill effects upon the 
general condition of the child. The dangers which arise from the de- 
velopment of tuberculosis must also be borne in mind. 

Treatment. — The treatment of acute pleurisy during the early days of 
the attack, before an exudation of any considerable extent has appeared, 
should be directed to the relief of the pain by a flannel bandage closely 
applied to the thorax, so as to allow the ribs to move as little as possible 
in respiration. Sometimes an occasional dose of tinctura opii campho- 
rata will also be needed to make the child comfortable. After the fluid 
has increased, the child should, if possible, be kept in bed. There are 
some cases, however, in which a child with considerable exudation in its 
pleura will feel well and bright, and will play about its nursery without 
showing any especial symptoms of discomfort. I have met with instances 
of this kind where, except for pallor and a poor appetite, the child seemed 
bright and active, and yet had a pleuritic exudation large enough to dis- 
place the heart. 

The child should be examined each day in reference to an increase in 
the quantity of fluid and to a displacement of the heart. If neither oc- 
curs, and if the respiration and circulation show no evidence of disturbance, 
an expectant treatment is all that is required. If, on the contrary, the 
fluid is increasing and the heart is displaced to any considerable degree, 
or if absorption of the fluid is delayed for two or three weeks, the chest 
should be aspirated. The point of aspiration should usually be in the 
fourth or fifth interspace in the midaxillary or posterior axillary line, 
but in deciding where to enter we should always be guided by the indi- 
cations given by the physical signs. A bacteriological examination of the 
fluid removed should then be made, to determine which form of organism 
is present in the exudate. If one of the more benign forms of bacteria is 
present, such as the pneumococcus, or if the fluid is found to be serous, 
no further treatment will be required, unless there be a reaccumulation 
of the fluid, in which case a second aspiration will be indicated. If, how- 
ever, streptococci are found in the exudate, the case must be watched 
very carefully, as it is more likely to become purulent and to need radical 
surgical treatment. 



DISEASES OF THE PLEURA. 713 

As the unfavorable symptoms in a pleuritic effusion arise mostly from 
intra-thoracic pressure, relief from the pressure by aspiration is indicated 
rather than by the use of drugs, which cannot be depended upon. 

Acute Pleurisy with Purulent Exudation. — Empyema. — In the 
first three or four years of life purulent exudations into the pleura are 
much more common than serous or sero-fibrinous exudations. Nearly 
all the cases which are secondary to lobar or broncho-pneumonia, repre- 
senting the largest group in children, are caused by the pneumococcus. 
The presence of other organisms has already been referred to. 

Pathology. — The inflammatory process begins with an exudation of 
fibrin upon the surface of the pleura, accompanied by an excessive migra- 
tion of leucocytes and a rapid accumulation of pus. The exudation may 
occasionally be sero-fibrinous at first and subsequently become purulent. 
In cases of streptococcus and staphylococcus infections, the inflammation 
may be purulent from the beginning, but the pus is not so thick and 
contains less fibrin than in pneumococcus infections. The pus may be 
encysted, but this rarely occurs in an empyema following pneumonia. 

When no bacteria are found in the fluid, when there is no history of 
a preceding acute pneumonia or a neoplasm of any kind, when there 
is little tendency to absorption of the exudate, and when the exudate is 
found to contain blood, the signs point strongly towards a tubercular 
origin. 

Symptoms. — The disease when primary may be acute in its onset, and 
may simulate closely the initial stage of lobar pneumonia. When second- 
ary to pneumonia or some other acute infectious disease it is slow and 
somewhat insidious in its development. The pulse and respirations may 
be increased, but after the early days of the disease they are often very 
little raised. There is nothing characteristic in the temperature of an em- 
pyema, and the diagnosis usually can be made only from the knowledge 
that the younger the individual the more likely is pus to be present. 
Cachexia, anaemia, and prostration soon become prominent. A pro- 
nounced leucocytosis is present from the onset and is the most important 
symptom in the differential diagnosis from a purely sero-fibrinous exuda- 
tion, which rarely shows more than a moderate increase in the white 
cells. Leucocytosis may at times be absent when aspiration shows pus 
to be present, but this is unusual and may be only temporary. 

The physical signs are the same as in sero-fibrinous exudations and 
have been described on page 709. 

The absorption of a purulent exudate without surgical interference is 
very rare. I have occasionally met with cases in which one or two 
aspirations were all that were necessary and in which complete absorp- 
tion seemingly took place. 

When cases of empyema are left untreated, a spontaneous opening 
usually takes place through some portion of the thoracic walls, but the 
exudate may also find its exit through the lungs by opening into one of 



714 PEDIATRICS. 

the bronchi or perforating in other directions, I have met with cases 
in which the diaphragm was perforated and the point of exit of the pus 
was in the region of the umbilicus. When perforation does not occur, 
the pus is partially absorbed, adhesions are formed, and sometimes great 
deformity of the chest follows, which may result in a marked degree of 
lateral curvature of the spine as well as in great contraction of the chest. 

Diagnosis. — The diagnosis of empyema rests upon the signs of fluid 
in the pleural cavity associated with a pronounced leucocytosis, but it 
cannot be made definitely without the aid of the aspirator. In all doubtful 
cases the aspirator should be freely used, for the consequences of a 
neglected empyema are very serious. 

The differential diagnosis of empyema is to be made from a number 
of different lesions. 

From Pneumonia. — The conditions which are most likely to be con- 
founded with a pleural exudation are acute and unresolved pneumonias. 
The difficulty arises from the frequency of bronchial breathing and bron- 
chophony and normal tactile fremitus over a pleural exudation in early 
life. When the physical signs are those both of fluid and of consolida- 
tion, the diagnosis must rest upon the results of exploratory aspiration. 
It is to be borne in mind, however, that aspiration frequently yields a 
negative result even when fluid is present, and several punctures may 
be necessary before the diagnosis can be settled. The possibility of 
pneumonia and pleurisy with exudation being combined should not be 
forgotten in making the differential diagnosis. 

From Atelectasis. — A simple bronchitis in children may cause an occlu- 
sion of the bronchi and produce atelectasis of the lungs, the signs of 
which may simulate closely a small effusion. Coughing and deep inspira- 
tion will, however, often remove the mucous plugs and allow the air to 
enter, so that the condition is readily determined. If the atelectasis per- 
sists, the signs may suggest an encapsulated empyema, and aspiration must 
be resorted to. 

From Sero- Fibrinous Exudations. — The diagnosis from sero-fibrinous 
exudations is very difficult, but the younger the individual the more likely 
is the fluid to be purulent. After the first week or ten days of the dis- 
ease, however, when the fluid is purulent, the usual signs of absorption 
which so commonly occur in a serous exudation are not ordinarily found, 
and aspiration of the pleural cavity will then determine which form of the 
disease is present. Marked leucocytosis favors the diagnosis of empyema. 

From Chronic Adhesive Pleurisy. — The signs of chronic adhesive 
pleurisy may exactly resemble those of fluid. If the diagnosis is doubt- 
ful aspiration will make it clear. 

Prognosis. — The prognosis in empyema is good if the diagnosis is 
made early, if the pneumococcus is the cause, and if the case is properly 
treated. If the infection is from the streptococcus pyogenes or the tubercle 
bacillus the prognosis is very unfavorable. If the pus has been allowed 



DISEASES OF THE PLEURA. 715 

to remain in the chest for a long period, the chances of recovery are 
proportionately diminished. Spontaneous recovery rarely occurs. In 
infants under one year the mortality is usually much higher than in later 
periods, especially in hospital practice. 

Treatment. — The treatment of empyema is essentially surgical, and I 
shall not enter into its details. After the first aspiration, if absorption 
does not occur within a week and if the infection is due to the pneu- 
mococcus, it is well to wait a week before deciding on a second aspira- 
tion or operation. If one of the more virulent forms of bacteria is found 
in the exudate, a radical operation is the best method of treatment and 
should be performed at once. Sometimes one aspiration of the pus will 
be followed by permanent and entire recovery. This, probably, only 
occurs in infections due to the pneumococcus, and I have seen such a case 
in an infant seven weeks old. I have also seen recovery follow after two 
and even three aspirations. The pleural cavity should be thoroughly 
drained by means of drainage-tubes. In many cases, especially in chil- 
dren over two or three years of age, resection of one or two ribs gives the 
Lest results. Although in some cases a rapid cure in two or three weeks 
follows the operation, yet the recovery is often prolonged for many 
months, even when strict antiseptic precautions have been taken at the 
time of the operation. 

The following cases illustrate pleurisy with sero-fibrinous exudation : 

A girl, eleven years old, was attacked with a chill followed by vomiting and a 
short, dry cough. Later she complained of pain in the lower part of the right chest. 
She was feverish, lost in weight and in appetite, and her respirations were painful. 
She lay most comfortably on her back and on her left side. A pleuritic friction-rub 
was heard in the right axillary region. Her lips and cheeks were slightly cyanotic. 
Her tongue was somewhat coated. The alae nasi were working and orthopuoea was 
marked. The percussion and auscultation of the left lung showed nothing abnormal. 
The resonance was fair over the upper part of the right front and back. There was 
flatness from about the fifth dorsal vertebra in the right back to the base of the lung. 
The flatness extended into the axillary region, where it reached its highest point, and 
then gradually descended to the right parasternal line on a level with the fourth costal 
cartilage. Over this area of flatness respiration was markedly diminished. No friction- 
Tub was heard. The vocal and the tactile fremitus were diminished. The impulse of 
the heart was found in the fourth interspace, 1 cm. (f inch) to the left of the mam- 
miliary line. The heart-sounds were normal. There was no displacement of the liver. 
An examination of the urine showed it to be acid, to have a specific gravity of 1022, 
to be of normal color, and to contain no albumin. The chlorides were normal. The 
temperature was 38.3° to 40° C. (103° to 104° F.) for the first two days and then 
gradually declined to normal in the course of three Aveeks. The pulse and respirations 
were irregular, the former ranging between 80 and 120, and the latter between 25 and 
50. The physical signs were those of a pleuritic effusion of the right side with dis- 
placement of the heart to the left. 

The area of flatness gradually decreased, and an exploratory aspiration showed 
the fluid to be serous. Nine weeks from the beginning of the attack, the dulness on 
percussion gradually disappeared, auscultation showed the respiration to be normal, 
and the heart resumed its normal position. 



716 PEDIATRICS. 

In another case of serous effusion in the pleura, the temperature ranged between 
37.2° and 38.8° C. (99° and 102° F.) for three weeks and suddenly dropped to normal. 
In the beginning 165 c.c. (5 \ ounces) of fluid were withdrawn from the chest. The 
fluid reaccumulated, so that absolute dulness was found over the whole right side of 
the chest in front and behind, but aspiration did not have to be resorted to again, and 
complete absorption took place thirty days from the beginning of the attack. 

Another case which illustrates the difficulty in diagnosticating a purulent 
effusion in the pleura in the early days of the disease is the following : 

A girl, four years old, was suddenly attacked with cough, and pain in the right 
side. The temperature was 40.5° C. (105° F.). The respirations were quickened, 
and the pulse was rapid. Nothing abnormal was detected on physical examination. 
On the following day the general symptoms disappeared, and the temperature fell to 
38.8° C. (102° F.). In another day the temperature fell to 37° C. (98.6° F.), and the 
child seemed bright and well. On the following day, however, the temperature rose 
to 40° C. (104° F.), flatness and the other signs of fluid were detected in the right axillary 
region, and an exploratory aspiration showed the presence of pus. 

CHRONIC PLEURISY. 
Chronic pleurisy results from previous attacks of acute inflammations 
of the pleura, either with or without the formation of fluid. The result 
is essentially the same, differing chiefly in degree. The lesions are repre- 
sented by adhesions between the thickened layers of parietal and visceral 
pleura. Large or small areas of the cavity may thus be obliterated. The 
physical signs are represented chiefly by dulness and diminution in the 
intensity of the breathing, voice-sounds, and tactile fremitus. Litten's 
phenomenon is absent. On the other hand, adhesions are often found at 
the autopsy, where during life both lungs seemed perfectly normal. The 
diagnosis is aided by the use of an aspirating needle, by which we can 
often determine by the sense of touch whether the needle is in a thick- 
ened pleura, the lung, or a free cavity. If the adhesions are extensive, 
retraction of the chest with certain compensatory changes occur as illus- 
trated in the following Case. 

A little girl, three years old, had an attack two years previously of some pulmo- 
nary disease accompanied by fever. From that time until she was first seen she was 
delicate and coughed a great deal. Her cough had increased, but she did not lose in 
weight nor have any other abnormal symptoms. She was pale, and the cervical, 
axillary, and inguinal glands were enlarged. Her fingers were markedly clubbed. 
She showed a peculiar lateral curvature of the spine, which could not be made to dis- 
appear by traction. The right side of the thorax expanded normally, the left side 
scarcely at all. There were hyperresonance, no rales, and compensatory respiration 
over the right lung. The left lung was apparently atelectatic and showed dulness 
everywhere except in a small triangular area at the inferior angle of the scapula. This 
deformity of the thorax was probably the result of an empyema which occurred when 
she was one year old and was not properly treated. 

Treatment. — The treatment consists entirely of general hygiene and 
systematic exercises of the chest. 



DISEASES OF THE PLEURA. 717 

HYDROTHORAX. 

Hydrothorax is a non-inflammatory affection, characterized by the 
transudation of a simple fluid into the pleural cavities. It is a rare affec- 
tion in children. The effusion is the result of mechanical obstruction to 
the flow of the subpleural blood and lymph. The principal causes for 
this obstruction are found in diseases of the heart and kidneys. The fluid 
is generally bilateral ; in some cardiac cases it may be unilateral. It is 
apt to be greater in amount on one side than on the other. 

The transudation is watery in character, of low specific gravity, under 
1015, and contains less albumin than inflammatory exudations, generally 
from one to two per cent. It does not coagulate spontaneously unless 
complicated with the exudation of an inflamed pleura. A few leucocytes, 
red blood-corpuscles, and endothelial cells may be found when the sedi- 
ment obtained by the centrifuge is examined microscopically. 

Symptoms. — The symptoms are in most cases simply those of the con- 
dition to which the hydrothorax is secondary. If the fluid is excessive 
there is a sense of constriction beneath the sternum, dyspnoea, and short, 
rapid respirations, weak pulse, and sometimes cyanosis. Any of these 
symptoms may be due to the primary disease alone, and it is therefore 
of much importance to watch the lungs carefully in all advanced and 
serious cases of cardiac and renal disease associated with dropsy. 

The physical signs are those of pleurisy with exudation. There is 
no friction-rub, as the pleurae are not inflamed, and the fluid shifts more 
readily on change in position, because of the absence of inflammatory 
adhesions. 

Diagnosis. — The diagnosis can be made from inflammatory exudations 
by the chemical examination of the fluid obtained by aspiration. 

Treatment. — The treatment is that of the primary disease to which 
the hydrothorax is secondary. If the symptoms of pressure are serious, 
repeated aspiration is generally necessary. 

PNEUMOTHORAX. 

Pneumothorax, or air in the pleural cavity, rarely occurs alone. It is 
generally associated with serous or sero-fibrinous fluid, and is then called 
hydropneumothorax ; or with pus, when we speak of it ^pyopneumothorax. 

Etiology. — Air may enter the pleural cavity from penetrating wounds 
from without, such as may result from aspiration. The most frequent 
cause, however, is due to perforation of the visceral pleura in the course 
of pulmonary tuberculosis, gangrene, or abscess. Nine-tenths of the 
cases, according to Fraentzel, are due to pulmonary tuberculosis. The 
condition is of rare occurrence in children. 

Pathology. — As a result of the entrance of air into the pleural cavity, 
the lung collapses and is withdrawn into the upper and posterior part of 
the pleural cavity. The amount of retraction depends upon the extent 
of the pleural adhesions or consolidation present. The entrance of air 



718 PEDIATRICS. 

is generally accompanied by micro-organisms, and by the conditions which 
follow a sero-fibrinous or purulent inflammation of the pleura. 

Symptoms. — The onset when sudden is characterized by severe pain in 
the side, dyspnoea, a weak, rapid pulse, and great prostration. Some- 
times the pneumothorax develops insidiously without giving rise to these 
symptoms of distress. The physical signs are distinctive. 

Inspection. — Respiration is diminished on the affected side and 
Litten's sign is absent. The heart may be displaced in the same way 
as by a pleuritic effusion. 

Palpation. — Tactile fremitus is absent over the lower part of the 
chest, but may be normal or even increased at the upper posterior por- 
tion over the retracted lung. The liver is generally displaced if the 
pneumothorax is on the right side. The apex of the heart will also be 
found to be displaced as in effusions. 

Percussion. — Tympanitic resonance is pronounced throughout the 
affected side, and may be so marked as to mask the presence of small 
effusions. When the air within the pleural cavity is very tense, the per- 
cussion-note may be muffled, simulating dulness. 

Auscultation. — The respirations and voice-sounds are very faintly 
heard or are absent in the lower portions of the chest, whereas at the top 
a faint amphoric or metallic breathing may be heard. If one coin is tapped 
against another coin placed on the back over the tympanitic area, the 
metallic echo is readily transmitted to the stethoscope on the front of the 
chest, and is quite characteristic. When the pneumothorax is accom- 
panied by fluid, as is generally the case, the signs of pneumothorax and 
fluid are combined and vary in their character according to the relative 
predominance of fluid or air. The sound of splashing obtained by suc- 
cussion is very distinctive of air and fluid, but must not be confused with 
similar sounds transmitted from the stomach. The difference can be 
made out by attention to the position of the intensity of the sound. 

Diagnosis. — Only when the air is very tense, and gives a muffled or 
dull note, will the physical signs resemble those of fluid. If the diagnosis 
is doubtful, aspiration will make it clear. Very large tubercular cavities 
may give rise to the signs of pneumothorax, but they are rare in children, 
and even when present are not associated with succussion or displace- 
ment of organs. 

Pneumothorax and emphysema resemble each other in the signs of 
feeble breathing and hyperresonance, but emphysema is almost always 
bilateral, with the coarse moist rales of an associated bronchitis, and does 
not displace the heart or liver, although it may alter the cardiac and 
hepatic areas of dulness. 

Prognosis. — The prognosis of pneumothorax depends largely upon 
the primary condition to which it is secondary. 

Treatment. — The treatment is essentially the same as that of pleurisy 
with effusion. 



DIVISION XL 

DISEASES OF THE HEART AND PERICARDIUM. 



DISEASES OF THE HEART. 

Cardiac disease in infancy and early childhood may be divided into 
congenital or acquired, developmental or inflammatory, organic or func- 
tional, acute or chronic. In this early period of life cardiac disease has 
certain characteristics in which it differs essentially from those which are 
met with in later life. One of these characteristics is that there is a more 
decided tendency to recovery than at a later period. Another is that,, 
owing to the undeveloped condition of the infant and young child, inter- 
ference with the growth of other organs and parts of the body may more 
easily result from diseases connected with the circulation than is possible 
in the case of the fully developed adult. Thus, there are certain ana- 
tomical facts connected with the ossification of the sternum Avhich be- 
come of great importance in connection Avith cardiac disease. Deformi- 
ties of the thorax may result from the continued pressure of the enlarged 
heart on the soft and pliant sternum and costal cartilages of the young 
subject. These deformities do not arise merely when the individual is" 
rhachitic, but may also depend upon the stage of development at which 
the cardiac disease begins. The deformity is more or less pronounced hi 
inverse ratio to the age and in direct ratio to the time during which the- 
cardiac disease has existed. The shape and extent of the deformity are 
also dependent upon the degree of ossification which has taken place in 
the sternum. 

In young infants, in whom the entire sternum is in a cartilaginous con- 
dition, the intra-thoracic pressure from an enlarged heart may cause a 
bulging of the whole front of the thorax. This may occur during the first 
year, and even up to the third year. As the child grows older, the manu- 
brium and the second piece of the sternum become ossified and offer more 
resistance, while the third piece of the sternum, still remaining in a semi- 
cartilaginous condition, may be tilted. This latter displacement may 
occur in children in whom the cardiac disease has not developed until the 
fourth, fifth, or sixth year. I have had under my care a child seven 
years old who at the age of five years had articular rheumatism with 
resulting cardiac hypertrophy, and who presented this displacement of 

719 



720 PEDIATRICS. 

the third piece of the sternum. No other signs of rhachitis were de- 
tected. The middle period of childhood is also a peculiarly unfortunate 
one for the occurrence of cardiac disease, because the heart grows so 
rapidly at this period that it requires a proportionately greater amount of 
intra-thoracic space for the normal performance of its function than it 
does later. 

In addition to the injury which may be done to the thoracic walls by 
an enlarged heart, we must consider the interference with the normal 
uniform expansion so necessary for the growing pulmonary tissue and 
the consequent loss of the elasticity which plays so prominent a part in 
the establishment of the equipoise which should exist in a perfected 
respiratory apparatus. 

The occurrence of diseases of the blood-vessels is rare in infancy and 
early childhood in comparison with later life. Aneurism is rare. A 
narrowing of the isthmus aortce is more common, and is one of the most 
marked of the congenital defects of the blood-vessels. It may result in 
increased blood-tension, followed by hypertrophy of the left ventricle 
and subsequent dilatation. Sometimes there is an absence of the isthmus 
aortce during fcetal life. The compensation for this defect takes place by 
an increased action of the left ventricle and the establishment of a col- 
lateral circulation between the subclavian artery and the thoracic and the 
abdominal aorta. These malformations exert in varying degrees an in- 
fluence on the heart, as the infant grows older, from increased blood- 
pressure. 

CONGENITAL DISEASES OF THE HEART. 

Congenital diseases of the heart are somewhat obscure in their 
etiology, but usually result either from an interference with the normal 
development of the organ or from endocarditis, or from a combination 
of both. The parts of the fcetal circulation at birth which are of most 
importance in reference to diseased conditions of the heart and great blood- 
vessels are the foramen ovale and the ductus arteriosus. When these 
remains of the fcetal circulation, which are normal during intra- uterine 
life and for a short period afterwards, continue as the infant grows older, 
they become abnormal and interfere with the equilibrium of the circu- 
lation. 

When the development of the heart has been interfered with in intra- 
uterine life, there results another set of malformations, the chief of which 
are an open ventricular septum, a transposition of the great vessels con- 
nected with the heart, and various malformations of the valves, such as 
atresia of the orifice, absence of one or more cusps, or supernumerary 
segments. There may also be absence of one of the large vessels. 
When, again, an inflammatory condition has taken place in intra-uterine 
life (fcetal endocarditis), various other morbid conditions result, usually 
located in the right side of the heart, the most common of which are 



CONGENITAL DISEASES OF THE HEART. 721 

connected with the pulmonary artery, causing stenosis or atresia, a nar- 
rowing of the conus arteriosus, and various malformations of the tricuspid 
valve and other orifices of the heart. These inflammatory lesions of the 
valves result in dilatation and hypertrophy of the heart and prevent its 
normal development by keeping open, for the purpose of compensation, 
the foramen ovale, the ventricular septum, and the ductus arteriosus. 
The valvular lesions vary greatly in their extent and pathology. 

It is sometimes very difficult to distinguish between the lesions re- 
sulting from foetal endocarditis and errors of development. The nodules 
of Albini and the small hemorrhages which are so commonly found 
on the cardiac valves in children, must not be mistaken for endocar- 
ditis. The form of inflammation of the endocardium which occurs in 
intra-uterine life is the chronic or sclerotic variety. Verrucose endo- 
carditis is rare. 

A deficient filling of the left side of the heart in early life, such as 
occurs in cases of atelectasis, foetal pneumonia, or foetal endocarditis, 
especially when stenosis of the pulmonary artery has resulted, may delay 
the closure of the foramen ovale and of the ductus arteriosus, which 
under these circumstances act as safety-valves. This is true also of the 
delay in the closing of the intra-ventricular septum, which is often of 
great aid in preserving the equilibrium of the circulation. The most 
common congenital cardiac lesions are an affection of the pulmonary 
artery, an open foramen ovale, an open ventricular septum, and an open 
ductus ateriosus. 

Transpositions of the aorta and pulmonary artery are very com- 
monly met with in connection with other congenital defects, such as spina 
bifida or hydrocephalus, but may occur in infants who are otherwise 
normally developed. In these cases the duration of life is almost in- 
variably short. 

Although these various abnormal conditions may be found alone, yet 
they generally occur in combination with each other, and all kinds of 
transpositions and malformations of the vessels are at times met with. 

There are various other malformations of the heart which occur at an 
early period of foetal development, and which are of pathological rather 
than clinical interest. Of these can be mentioned cases in which there are 
one auricle and one ventricle (cor biloculare), or one ventricle and two auri- 
cles (cor triloculare), as well as a case which has come under my notice, in 
which the heart had a double apex, the right apex lying in the fourth 
interspace to the right of the sternum, and the left apex lying in the 
fourth interspace to the left of the sternum. At times there may be a 
double heart, absence of heart (acardia), heart on the right side (dextro- 
cardia), or the heart may be in various parts of the thorax or abdomen. 

General Symptoms. — Although in some cases the symptoms of con- 
genital cardiac disease are very indefinite, and the disease may be masked 
for a number of months, yet in a large number of cases they soon be- 

46 



722 PEDIATRICS. 

come evident. The typical symptoms of congenital cardiac disease are 
cyanosis and attacks of dyspnoea, amounting at times to suffocation, and 
imperfect development. As the disease progresses, the fingers and toes 
often become club-shaped, the nails blue, and the skin cool. In connection 
with these rational signs there is usually an evident pulsation in the cardiac 
region, with bulging of the precordia. When the obstruction caused by 
the lesions is sufficient to produce hypertrophy and dilatation of the 
heart, an increase in the area of cardiac dulness is found. Diffuse cardiac 
murmurs are heard often over the whole chest, but usually have their 
maximum intensity towards the upper part of the sternum, are commonly 
systolic in time, and in some cases are accompanied by a thrill. 

The most common symptom is cyanosis. Cyanosis may arise from 
incomplete oxygenation of the blood, and not merely from a mixture of 
the venous and arterial currents. When cyanosis is present to any extent 
there is usually some malformation of the pulmonary artery or its valves. 
Well-marked congenital malformations may be present with no symptoms 
whatever. There may be an entire absence of cyanosis ; there may be 
no increased area of dulness and no murmurs ; and I have met with 
instances in which the infants seemed to be thriving, and showed neither 
labored breathing nor physical signs of disease up to within a few hours 
of death, and yet a number of cardiac malformations were found at the 
autopsy. Although, as a rule, the symptoms occur at a very early period 
of extra-uterine life, yet quite frequently they are so mild in character 
that they are not especially noticed, as they may appear only when the 
infant is much excited or crying. The cardiac symptoms may not be 
prominent enough to attract attention until the infant is old enough to 
exert itself sufficiently, as by creeping or walking, to interfere with the 
equilibrium of its circulation. At times another disease, especially bron- 
chitis or pneumonia, may precipitate the cardiac symptoms. It is quite 
common for endocarditis to develop in a heart in which a congenital 
malformation is present The diagnosis between a congenital and an ac- 
quired cardiac affection then becomes necessary and is accompanied by 
many difficulties. 

The following case illustrates how congenital cardiac disease can be 
masked for a number of weeks : 

The infant was apparently healthy at birth, and a careful physical examination 
showed nothing abnormal in the thorax. There was no cynosis noticed, the skin 
being of a normal color. When it was sixteen days old it refused to take the breast, 
and in the afternoon seemed somewhat cold, was slightly cyanotic, and had a tem- 
perature of 35.2° G. (95.5° F.). An examination of the heart detected nothing 
abnormal. A few drops of brandy were given to it, and after several hours the skin 
became warm, the respirations normal, and it took its food as usual. Early in the 
following morning the quickened respiration returned, the temperature rose to 37.7° C. 
(100° F.), it refused to take its food, failed rapidly, and died in the afternoon. 

The examination of the heart showed a large open foramen ovale and an absence 
of the upper part of the intra-ventricular septum below the aortic valve, The be- 



CONGENITAL DISEASES OF THE HEART. 723 

ginning of the aorta for a distance of 1 cm. (f inch) was dilated into a spherical 
pouch, from which were given off (1) the aorta without any branches before the inter- 
costals, thus supplying only the lower part of the body, (2) a large vessel to the right 
lung, and (3) a large vessel to the left lung. From the upper part of the right ven- 
tricle was given off a large vessel which divided 1.4 cm. (J inch) above the pulmonary 
valve into a large vessel on the right side and two smaller ones on the left. The large 
vessel apparently corresponded to the innominate, and the other two vessels to the 
subclavian and common carotid of the left side. By these vessels blood was supplied 
to the head and upper extremities. There was no communication between the arterial 
and pulmonary vessels, as the ductus arteriosus was absent. The cause of the dila- 
tation of the beginning of the aorta was a thickening and narrowing of the vessel for 
8 mm. (J inch) just beyond the dilatation. The heart was enlarged, but not especially 
hypertrophied. 

There was a general streptococcus invasion, for which no source could be found. 
The cord had come away at the usual time without leaving any abnormal condition in 
the neighborhood of the umbilicus. 

General Diagnosis. — Although it is usually possible to make a diagnosis 
of congenital cardiac disease, yet when we consider the variety of lesions 
which may occur, and the combination of different lesions which may be 
present, with the same symptoms or a marked lack of symptoms, it will 
be understood that a diagnosis of the especial lesion is often impossible. 

Bearing in mind the mechanism of the fcetal circulation and the con- 
nection which an enlargement of the heart has with especial lesions, we 
can sometimes arrive at an approximately correct diagnosis. Too much 
reliance, however, must not be placed upon the locality or sound of the 
cardiac murmurs, as such murmurs may be produced by very trivial 
lesions, and may be absent when the lesions are most pronounced. The 
following characteristics may, however, be considered to represent the 
more common congenital anomalies. 

OPEN FORAMEN OVALE. 

One of the most common congenital malformations of the heart is 
represented by a defect in development of the auricular septum by an 
open foramen ovale. The failure of the foramen ovale to close is usually 
caused by an interference with the pulmonary circulation, such as may 
occur in atelectasis. Premature closure of the foramen ovale has been 
met with, but is extremely rare. 

So long as the patent foramen ovale is not associated with other de- 
fects it does not, as a rule, produce a murmur or give rise to any symp- 
toms. The reason for this is supposed to be that the blood can only flow 
from the right auricle into the left when the pressure is greater in the 
former, and it is not greater unless there is some obstruction either at the 
tricuspid valve or in the pulmonary valve or artery, by which the flow 
of the blood-current into the right ventricle is interfered with. 

When symptoms such as cyanosis or murmurs are met vyth in connec- 
tion with an open foramen ovale, they almost always depend on asso- 
ciated lesions, the most common of which are stenosis of the pulmonary 



724 PEDIATRICS. 

artery and a defect in the ventricular septum. The prognosis in uncom- 
plicated cases of patent foramen ovale is good, as the lesion is one which 
need not cause much embarrassment of the circulation. 

DEFECT OP THE VENTRICULAR SEPTUM. 

A defect in the ventricular septum is a very frequent congenital lesion. 
It may be complete, but is usually partial, and is most common in the upper 
part. This defect rarely occurs alone, but is associated with other lesions, 
especially stenosis of the pulmonary artery, and in such cases acts as a 
safety-valve. An abnormal origin of the great vessels is also frequently 
found with this defect. As the lesion is so frequently associated with 
other anomalies, there are no sharply marked and distinctive symptoms. 
In most cases, however, a loud systolic murmur is heard over the whole 
front of the chest, with its maximum intensity hardly ever near the apex, 
and with a notable absence of a palpable thrill. In uncomplicated cases 
hypertrophy of the ventricles is not marked. 

When the right ventricle is strong enough to resist the increased 
blood-pressure from the left ventricle, the circulation is carried on nor- 
mally without compensatory hypertrophy and without cyanosis or dropsy. 
When, however, great expiratory efforts occur, as in bronchitis and per- 
tussis, or when the blood-pressure is increased from any other cause, 
dilatation of the right ventricle may set in acutely with symptoms of 
broken compensation, especially those of cyanosis and dropsy. These 
symptoms may, for a time, be delayed by a compensatory hypertrophy 
of the right ventricle. 

The prognosis must necessarily be uncertain and unsatisfactory, as in 
so many instances the defective septum is accompanied by other lesions. 
In most instances the infants die early, but cases have been reported in 
which they have lived for many years. 

LESIONS OP THE PULMONARY ORIFICE. 

There are three lesions of the pulmonary orifice which play a very 
important role in congenital cardiac disease. These are stenosis or atresia 
of the pulmonary orifice and stenosis of the conus arteriosus of the right 
ventricle. These lesions may occur alone, but most commonly are asso- 
ciated with a defect in the septa and with a patent ductus arteriosus. 
They may be the result of a fault in development or of a fcetal endocar- 
ditis. 

Pulmonary Stenosis. — This lesion is characterized by extreme cyano- 
sis, cold, livid extremities, clubbing of the fingers, rapid respirations, and 
a tendency to dyspnoea. The physical, like the rational, signs are more 
characteristic than in the other forms of cardiac anomalies. They consist 
chiefly of a loud systolic murmur heard most distinctly in the pulmonary 
region and transmitted in all directions. There is, according to the extent 
of the stenosis, a weak or absent pulmonic second sound ; if, however, 



CONGENITAL DISEASES OF THE HEART. 725 

the ductus arteriosus happens to be patent there may be no diminution 
in the intensity of the pulmonic second sound. In some cases a palpable 
systolic thrill may be felt in the pulmonary region. In many cases, how- 
ever, the murmur obscures and dominates all other sounds. Generally 
there is an increased area of cardiac dulness extending to the right of the 
sternum and representing hypertrophy of the right ventricle. 

Notwithstanding the apparent gravity of the lesion, pulmonary stenosis 
permits the infant to live, often for many years, but there is always in these 
cases a special tendency to tuberculosis and to pneumonia. 

Pulmonary Atresia. — This lesion is less common but much more 
serious than stenosis. It is so commonly combined with other anomalies, 
such as defects in the septa and patent ductus arteriosus, that it cannot be 
said to have any distinctive physical signs of its own, while its general 
symptoms are the same as those of pulmonary stenosis. 

Stenosis of the Conus Arteriosus. — This is an anomaly of develop- 
ment, is usually associated with other lesions of the orifice, and tends to 
accentuate the symptoms and results of such lesions. Pulmonary insuffi- 
ciency has been observed in certain cases, but is very rare. 

PERSISTENCE OF THE DUCTUS ARTERIOSUS 

This lesion when existing alone may, as in a case which has come 
under my observation, present no symptoms except slight and evanescent 
cyanosis. The sign which, in addition to a light grade of cyanosis and a 
cadaverous color, is most characteristic of this condition is a loud vibra- 
tory systolic murmur, with its greatest intensity at the base of the heart. 
If the lesion is unassociated with other anomalies, there is no hyper- 
trophy of the ventricles, but if, as so often occurs, there is obstruction at 
the pulmonary orifice, there is usually also hypertrophy of the right 
ventricle, and a diagnosis cannot be made, as the murmur cannot be dis- 
tinguished from that of pulmonary stenosis. 

The ductus arteriosus should gradually be obliterated within the first 
two weeks of extra-uterine life. Interference with this normal involution 
is not very uncommon, rarely occurs alone, and is usually found in con- 
nection with lesions of the pulmonary artery or narrowing of the isthmus 
aortae. Sometimes the process of obliterative endarteritis extends to the 
aorta and causes stenosis of the isthmus aortae. Again, the duct, in 
closing and retracting, pulls the aorta and tends to narrow that vessel, thus 
increasing the arterial tension. During fcetal life stenosis of the isth- 
mus aortae does not produce much disturbance in cases in which the 
ductus arteriosus can carry the blood to the descending aorta. At birth, 
however, in these cases, unless the ductus arteriosus remains pervious, 
serious symptoms arise. If life is prolonged, hypertrophy of the left ven- 
tricle takes place, and the arterial blood has to be conveyed to the de- 
scending aorta by means of a collateral circulation which is established 
between the branches of the subclavian arteries and the branches of the 



726 PEDIATRICS. 

thoracic and abdominal arteries. Premature closure of the ductus arterio- 
sus during foetal life has been met with, but is a rare condition. Very 
rarely the ductus arteriosus may be entirely absent. 

TRANSPOSITION OF THE LARGE ARTERIES. 

A transposition of the aorta and pulmonary arteries sometimes occurs 
when the former arises from the right and the latter from the left 
ventricle. Both arteries may arise from a common trunk, and a number 
of other anomalies which are very rare may exist. Transposition of 
the arteries is not an uncommon anomaly, but there are no symptoms by 
which the condition can be diagnosticated, as there may be an entire ab- 
sence of cyanosis, cardiac hypertrophy, and murmurs. The anomaly is, 
however, at times accompanied by intense cyanosis, asphyxia, cool skin 
and extremities, and apathy, but as it is always associated with other lesions, 
there are no distinctive symptoms by which a diagnosis can be made. 

When this transposition of the main arterial trunks occurs the infant 
usually lives but a short time. 

LESIONS OF THE TRICUSPID ORIFICE. 

Tricuspid Stenosis. — This lesion is usually the result of a fcetal 
endocarditis. It is very rare and is often associated with deficient de- 
velopment of the right ventricle and hypertrophy and dilatation of the left 
ventricle. 

Tricuspid Insufficiency. — This also is very rare, and results in 
hypertrophy of the right ventricle and dilatation of the right auricle. 

Both of these lesions are accompanied usually by a number of other 
anomalies, so that there are no distinct symptoms by which to make a 
diagnosis, but, as a rule, the cyanosis is pronounced, the heart impulse 
is unusually strong, there are extensive systolic and diastolic murmurs, 
thrills, venous pulsation in the neck, epigastric pulsation, and a tendency 
to hemorrhage. 

LESIONS OF THE MITRAL AND AORTIC ORIFICES. 

Although lesions of the left side of the heart may be produced by 
fcetal endocarditis, they are exceedingly rare, in comparison with lesions 
of the right side of the heart, and are generally associated with a number, 
of other congenital cardiac anomalies. Their symptomatic significance is 
the same as when they occur in extra-uterine endocarditis, and will be 
described under acquired diseases of the heart. It may be said, how- 
ever, that the signs of tricuspid, mitral, and aortic lesions do not differ 
materially from those met with in adults. 

The duration of life when the lesions are at the aortic orifice is not 
nearly so long as when the pulmonary orifice is affected. 

Differential Diagnosis of Congenital Disease of the Heart. — The 
differential diagnosis of congenital from acquired organic disease, and of 
the different varieties of congenital lesions, is exceedingly difficult at times, 



COXGEXITAL DISEASES OF THE HEART. 727 

and often cannot be made. Certain facts, however, which seem to be 
generally accepted, may be stated, and will sometimes aid in the diagnosis. 

Loud murmurs without much increase of cardiac dulness point 
towards congenital disease, while with increase of dulness they may be 
from either congenital or acquired disease. 

If there are loud precordial murmurs without thrill and without 
hypertrophy, which are heard with greatest intensity about in the centre 
of the area of cardiac dulness, the lesion is probably a congenital defect 
of the ventricular septum. 

If there is a thrill but no hypertrophy, the lesion is probably a con- 
genital patent ductus arteriosus. 

Fig 149. 

I. 





S, unclosed ventricular septum. Female. 10 months old. "Warren Museum, Harvard University. 

If there is a loud murmur at the base, with a weak pulmonic second 
sound, a thrill, and hypertrophy of the right ventricle, especially if there is 
marked and continued cyanosis, the lesion is probably pulmonary stenosis. 

Murmurs of congenital origin must be distinguished from those of a 
functional or hgemic source. In congenital disease the murmurs are loud, 
often accompanied by a thrill, except in defect of the ventricular septum, 
are associated with cyanosis, dyspnoea, and cardiac hypertrophy, and are 
permanent. Functional murmurs, on the other hand, are seldom so loud, 
are evanescent, are unaccompanied by other marked signs, excepting often 
pronounced anaemia and a venous hum, and usually can be traced to 
definite etiological conditions such as are described on page 748. 

Fig. 149 shows a small opening in the ventricular septum. 



728 



PEDIATRICS. 



In this case there was also an open foramen ovale, but no other 
malformation. The infant, after showing the usual progressive signs of 
congenital cardiac disease, died suddenly. There was no history of 
cyanosis. 

Fig. 150. 




Congenital cardiac disease. Male, 4% years old. Right and left ventricles laid open by two cuts. 
Stenosis of pulmonary orifice. Incomplete septum ventriculorum. 1 and 1', septum ventriculorum cut 
across ; 2, aortic valves ; 3, probe passing through narrowed pulmonary orifice ; 4, bent probe, passing 
through right ventricle to left through opening in septum ventriculorum. 

Fig. 150 represents a specimen taken from a boy four and a half years old, who 
during life had shown cyanosis, clubbed fingers, and at times severe dyspnoea. The 
physical signs in connection with the heart were a fine wave perceptible to the eye at 
the left third interspace, a soft, purring thrill over the base of the heart, cardiac pul- 
sation 1.4 cm. (| inch) outside of the left mammillary line, and cardiac dulness from 
the right sternal margin to the left mammillary line, with no dulness to the right of the 
sternum. A loud, harsh systolic murmur was heard over the left margin of the 
sternum, most marked at the second left interspace and third rib, and not transmitted 
to the left or along the aorta. 

Fig. 151. 




Transverse section of heart near apex. 1, right ventricle ; 2, left ventricle. 



The pulmonary artery was abnormally small, the aorta was abnormally large, the 
conus arteriosus was practically obliterated at the pulmonary orifice, and the ventricu- 
lar side formed a ring of white cicatricial tissue J cm. (^ inch) in diameter. 

Fig. 151 represents the same heart with the apex cut away so as to show the rela- 
tive thickness of the ventricular walls and the greatly thickened septum ventriculorum. 

The right ventricle was markedly hypertrophied. The left ventricle was normal. 
The ventricular septum was greatly hypertrophied. In this case the ductus arteriosus 



CONGENITAL DISEASES OF THE HEART. 729 

was impervious and the foramen ovale practically closed. A foetal endocarditis had 
taken place before the septum ventriculorum had closed. The endocarditis caused 
contraction of the conus, and the blood being forced from the right ventricle through 
the imperfect septum prevented the latter from closing. This provided a safety-valve, 
which, as usually happens in this form of malformation, allowed the child to live 
longer than is common in other congenital cardiac malformations. The aorta, receiving 
a direct stream from both ventricles, was distended ; the pulmonary artery, receiving 
but little, remained small. It is interesting to note in this case that the child passed 
through an attack of pertussis and measles without serious results. It died ultimately 
of abscess of the brain. 

Fig. 152 shows an open ductus arteriosus. 

Fig. 152. 





D, open ductus arteriosus. Male, 16 days old. Warren Museum, Harvard University 



This heart, which was left attached to the lung, was taken from an infant, sixteen 
days old, who was apparently healthy at birth and presented no symptoms of cardiac 
disease. 

When the infant was five days old it was noticed that it would sometimes become 
slightly cyanotic. At this time its temperature rose to 39.4° C. (103 c F.). A physical 
examination showed nothing abnormal, and nothing unusual was seen on inspection. 
The area of cardiac dulness was normal, and no murmurs were detected. A day or 
two later the temperature became normal ; the cyanosis increased somewhat, but was 
intermittent and of a very slight degree. At times the skin would become cool. A 
few days later there was slight intestinal disturbance. When sixteen days old, without 
any other symptoms having developed, the infant died suddenly. The post-mortem 
examination showed this widely open ductus arteriosus. The foramen ovale was also 
open. There were no other lesions, such as stenosis of the pulmonary artery, open 
ventricular septum, or lesions of the valves. The heart was of normal size. There 
were no signs of the obliterative endocarditis usually found at this age in the ductus 
arteriosus. 



730 PEDIATRICS. 

General Treatment. — The treatment of congenital disease of the 
heart is essentially hygienic and symptomatic. The infants should be 
carefully protected from atmospheric changes which would be likely to 
produce bronchial irritation, as in many cases bronchitis appears to play 
an important part in interfering with the maintenance of the equilibrium 
of the circulation and in destroying compensation. In a number of cases 
I have found that the administration of digitalis in small doses and with 
the greatest caution is valuable when hypertrophy has begun to fail and 
dilatation to increase. When the dyspnoea is distressing, a few drops of 
aromatic spirits of ammonia will often give relief. Stimulants are usually 
indicated. 

Freedom from excitement and over-exertion should be constantly en- 
forced, but the child should be kept in the open air, when it is warm and 
dry, as much as possible. Finally, infants and children with congenital 
cardiac disease should be closely watched, even when they seemingly are 
doing well, for they are apt to die suddenly. 

ACQUIRED DISEASES OF THE HEART. 

In studying acquired diseases of the heart it is important to recog- 
nize the relative size and position of the heart at different ages. These 
have been described on page 90. Acquired diseases of the heart are 
more apt to attack the left side of the heart than the right ; when the 
right heart is affected it is generally secondary to the lesions on the left 
side. 

There are certain differences between the symptoms of cardiac disease 
in infancy and early life and those in later life. In young children mur- 
murs are more apt to be diffuse than in adults, often being heard over the 
entire chest ; and -the rate and rhythm of the heart are so easily disturbed 
by nervous influences as to be of little diagnostic value. Progressive 
emaciation is a symptom which is apt to be pronounced and to appear 
early in the disease, especially if the child is young. 

An enlarged heart dependent on adhesions from a preceding pericar- 
ditis is more common in early life than in adults, while compensation is 
much more readily acquired. I have had children with cardiac disease at 
my children's clinic one year with cardiac symptoms so severe that they 
had to be carried ; they were emaciated and cyanotic, the area of cardiac 
dulness was increased, and souffles were present ; yet these same children 
would return and be shown to the next class of students in the following 
year, walking up-stairs without dyspnoea, looking well nourished, of good 
color, with much less enlargement of the area of cardiac dulness, and 
with the cardiac souffles scarcely perceptible, showing that the cardiac 
compensation was complete. 

Cardiac symptoms dependent on organic lesions may arise and yet no 
physical signs of such lesions be detected during life. 



ACQUIRED DISEASES OF THE HEART. 731 

CARDIAC HYPERTROPHY. 

Hypertrophy of the heart consists of an increase in thickness of the 
cardiac walls. It may be of one or both sides of the heart and is usually 
most marked in the ventricles. The hypertrophy may be of the walls 
without an accompanying dilatation of the cardiac cavities (eccentric), or 
dilatation of the cavities may be present, thus increasing the entire size of 
the heart. Cardiac hypertrophy is always an effort of nature to counter- 
act various morbid influences by maintaining the equilibrium of the circu- 
lation, — that is, it is compensatory. 

Etiology. — Hypertrophy of the heart is not in itself a disease, but may 
occur in many diseases whether of the Avails or of the valves. It is 
closely related to increased blood-pressure, which may arise from disease 
or circulatory disturbance outside of the heart or from imperfect valvular 
conditions within the heart. 

In the former case the most common causes in children are pericardial 
adhesions, prolonged pertussis, narrowing of the aorta, and nephritis, espe- 
cially that which follows scarlet fever. Mechanical interference with the 
action of the heart arising from adhesions of the pericardium is often 
latent in its symptoms in infancy, and its occurrence should be especially 
borne in mind. In the valvular lesions the increased demand for cardiac 
work beyond what is normally called for acts as an immediate cause for 
cardiac hypertrophy. 

Pathology. — The chief morbid conditions of cardiac hypertrophy are 
an increase in weight and an increase in size and number of the muscular 
fibres which is found not only in the cardiac walls but in the papillae and 
trabecule. If the left side of the heart is conspicuously enlarged, as in 
obstruction at the aortic orifice or in the general arterial system, the heart 
is elongated ; if the hypertrophy is of the right side, as in obstruction of the 
pulmonary circulation, the heart is widened. 

Symptoms. — So long as the compensation is complete, cardiac hyper- 
trophy does not produce in young subjects any marked symptoms, even 
the dyspnoea on exertion not being especially noticeable. 

Hypertrophy of the Left Ventricle. — In hypertrophy of the left ventricle 
the cardiac impulse is perceptible over an abnormally large area and the 
impulse is lower and further to the left than normal, the degree varying 
according to the extent of the hypertrophy. 

Palpation shows the impulse to be increased in force. Percussion 
shows the cardiac dulness to be markedly increased in extent downward 
and to the left. Auscultation shows the first sound at the apex to be long 
and low in comparison with the second sound, which is loud and sharp. 
There is accentuation of the aortic second sound. The pulse is full and 
strong. 

Hypertrophy of the Right Ventricle. — In hypertrophy of the right ven- 
tricle the cardiac impulse is especially marked further to the left than 



732 PEDIATRICS. 

normal and somewhat downward. There is nothing characteristic in the 
pulse. The area of superficial cardiac clulness is increased in width, 
notably to the right and often beyond the right sternal line. There is 
accentuation of the pulmonic second sound, but this accentuation, al- 
though almost always present in hypertrophy of the right ventricle, is not 
peculiar to this condition, as it may be present in varying degrees in 
young children normally and from such causes as jmeumonia and certain 
nervous conditions. 

Prognosis. — So long as full compensation is present the prognosis is 
favorable. It becomes proportionately unfavorable as the compensation 
lessens. 

Treatment. — The treatment is described on page 746. 

CARDIAC DILATATION. 

Cardiac dilatation occurs when the cavities of the heart are abnor- 
mally increased in volume. In many cases there is a thinning of the 
walls of the heart, as in acute dilatation, but when hypertrophy is present, 
as in certain chronic cases, the walls may be thicker than normal. 

Etiology. — Acute dilatation may occur from a weakening of the cardiac 
muscle caused by degeneration of the myocardium, as in certain infec- 
tious diseases and from poor nutrition. 

Chronic dilatation occurs slowly as the result of valvular lesions or in 
the progress of the circulatory disturbances spoken of as causing hyper- 
trophy. 

Pathology. — In simple dilatation, without hypertrophy, the weight of 
the heart is not increased, although there is increase in its size. The 
papillae are flattened, when the dilatation is marked, in comparison with 
the accompanying hypertrophy, and the endocardium is thickened and 
opaque. 

Symptoms. — The symptoms of cardiac dilatation are essentially those 
of a failure of compensation characterized by dyspncea on exertion, pal- 
pitation, cough, and, later, cyanosis and cedema. In both acute and 
chronic dilatation there are a weak, fluttering apex-beat and pulse, an 
increased area of cardiac dulness, and valvular murmurs varving accord- 
ing to the especial lesions. 

Dilatation of the Left Ventricle. — There is an increased area of cardiac 
dulness to the left and downward. The first heart-sounds are sharp and 
short. The aortic second sound is feeble both at the apex and in the 
aortic area. 

Dilatation of the Right Ventricle. — The chief signs of dilatation of the 
right ventricle are increase of the area of cardiac dulness to the right, 
corresponding to the region of the right auricle, and a weak pulmonic 
second sound. 

In all the conditions which cause dilatation there is a greater liability 
that acute dilatation may take place in early life than at a later period. 



ACQUIRED DISEASES OF THE HEART. 733 

The processes which suddenly cause great increase of the blood-pressure 
in the lungs may lead to acute dilatation of the right ventricle. When 
there is a diffuse renal disease, such as may develop in the course of 
scarlet fever, acute dilatation of the left ventricle may take place, and be 
followed by hypertrophy. In all these diseases this acute dilatation may 
take place rapidly and disappear almost as rapidly, a phenomenon which 
is somewhat characteristic of cardiac disease in early life. 

The great changes which take place in the heart and its rapid growth 
at the time of puberty have already been referred to. At this period the 
general growth of .the child is apt to be very rapid, and symptoms of car- 
diac weakness commonly occur, especially in girls. These symptoms are 
debility, lack of energy, palpitation, and dyspnoea on exertion. There 
may also be signs of slight cardiac dilatation, and murmurs, probably 
haemic in their nature. This period, therefore, is one in which cardiac 
disease from any cause, such as rheumatism, is of more serious import 
than at a later period, when the heart is not taxed by too rapid growth. 

Prognosis. — The prognosis of cardiac dilatation depends on wmether 
the cause is a temporary one or whether, in case it is not, compensatory 
hypertrophy can be obtained by treatment. Whether the prognosis is 
favorable or unfavorable must, then, be determined by the evidence of re- 
action which is presented by the individual case. 

Treatment. — The treatment is described on page 746. 

MYOCARDITIS. 

Primary disease of the myocardium is very rare in children, in whom 
disease of the myocardium is almost always a secondary process resulting 
from one of the infectious diseases. It may be acute or chronic. 

Etiology. — The most common causes in children are endocarditis, 
pericarditis, and the infectious diseases, especially scarlet fever and diph- 
theria. The other causes which may produce an affection of the myo- 
cardium in later life may occur at any age, but are too rare in children to 
be considered. They are found in lesions of the coronary arteries 
(anaemic necrosis), an excess of food, alcohol, physical strain, and arterio- 
sclerosis. 

Pathology. — The lesions may be parenchymatous or interstitial, de- 
generative or inflammatory. They are essentially of the septum and left 
ventricle. In the parenchymatous form the anatomical changes are in the 
muscle-cells, the cells being degenerated in various ways (granular, fatty, 
hyaline), and the muscular fibres often separated, a condition known as 
fragmentation and segmentation. This form is usually met with in fevers, 
intoxications, infectious conditions, and in connection with endocarditis 
and pericarditis. It is always acute, usually diffuse, and is especially 
characterized by softness of the heart. 

The interstitial form may be acute or chronic, and occurs in small areas. 
In the acute variety, such as occurs in certain infectious diseases, most 



734 PEDIATRICS. 

commonly in diphtheria and typhoid fever, and especially in acute pericar- 
ditis, which is an important local cause in childhood, there is an infiltra- 
tion of round cells between the fibres, and in some cases small abscesses 
are formed. In the chronic variety there are opaque, white or yellow 
spots which later may soften (Ziegler's myomalacia), and, as has occurred 
in rare cases in children, cardiac aneurism and rupture may result. The 
parenchymatous and interstitial lesions of the myocardium may develop 
alone or in combination. The other pathological lesions of the myocar- 
dium are so rare in children that they need merely be mentioned. They 
are fatty degeneration and infiltration, brovm atrophy, amyloid degeneration, 
hyaline transformation (Zenker), and calcareous degeneration. 

Symptoms. — The symptoms are essentially those of a weak heart, but 
as to whether such symptoms are indicative of an affection of the myo- 
cardium, or of nervous conditions of the heart, or of some other cardiac 
disease is usually very uncertain. 

In acute cases there may be palpitation, pallor, dyspnoea on slight 
exertion, a rapid, irregular, weak pulse, disturbance of digestion, and on 
auscultation feeble heart-sounds, especially the aortic second, and in the 
beginning absence of murmurs. Usually there is no increase in cardiac 
dulness. 

It must, however, be remembered that these same symptoms may be 
present and yet no lesion of the myocardium be found at the autopsy, 
while, on the other hand, without any especial symptoms referable to the 
heart, sudden death may occur and marked lesions of the myocardium be 
present. 

In chronic cases the weakening of the heart is slow and progressive 
and the area of cardiac dulness is increased, corresponding usually to the 
left side of the heart. The impulse is feeble and murmurs may eventually 
appear as the valves of the heart become incompetent. Symptoms of 
venous stasis gradually supervene. The pulse is irregular and small ; 
it is sometimes slow, but becomes rapid under even slight nervous ex- 
citement. All these symptoms may become intensified, but it must be 
borne in mind that other diseases may cause these same cardiac symptoms 
and that the autopsy may disclose serious chronic lesions of the cardiac 
walls where during life no cardiac symptoms had appeared. 

Diagnosis. — The diagnosis depends upon symptoms of cardiac weak- 
ness, with a rapid, irregular, feeble pulse, without murmurs, with or with- 
out increased cardiac dulness, upon the progressive character of the symp- 
toms, and upon the comparatively slight improvement under treatment. 
The etiological factor in the diagnosis is important. When a previously 
healthy child has been attacked by one of the infectious diseases, such as 
scarlet fever, diphtheria, or typhoid, and when cardiac symptoms not re- 
ferable to an endocarditis or pericarditis arise, we may suspect a lesion 
of the myocardium. 

Prognosis. — The prognosis in affections of the myocardium depends 



ACQUIRED DISEASES OF THE HEART. 735 

upon the cause of the condition and also, if it is secondary to one of the 
infectious diseases, upon the degree and virulence of the infection. It is, 
therefore, very uncertain in the acute cases, although always serious, 
while in the chronic cases it is very grave. 

Treatment. — The treatment is essentially rest and freedom from ner- 
vous excitement and sudden exertion, as from sitting up in bed. After 
such diseases as diphtheria a recumbent position is often indicated for 
weeks when marked signs of cardiac weakness have arisen ; and this 
may be said also when these symptoms supervene on any of the infectious 
diseases. Stimulants such as aromatic spirits of ammonia and alcohol 
should be freely used. Strychnine is, of all drugs, perhaps the most valu- 
able, while digitalis, if used at all, should be given with great caution and 
in small doses. When there is much precordial distress and the symp- 
toms of cardiac failure are imminent, small doses of morphia given subcu- 
taneously are indicated. Anaemia and other symptoms, if present, should 
receive appropriate symptomatic treatment. 

ENDOCARDITIS. 

Endocarditis is an inflammation of the endocardium which is usually 
confined to the valves. It may be acute or chronic. 

Acute Endocarditis. — The acute form of endocarditis may occur in 
foetal life, and in these cases almost invariably affects the right side of the 
heart, while if the disease is acquired in extra-uterine life it is the left side 
of the heart which is most frequently attacked. 

Etiology. — Acute endocarditis may, in rare instances, be a primary 
disease, but in most cases is caused by some one of various infectious 
processes. In some cases bacteria have been found, but not in all. There 
is no one variety of bacteria exclusively concerned in the production of 
acute endocarditis. The streptococcus, staphylococcus, pneumococcus, and 
gonococcus are the forms which have been most frequently found. Less 
frequently, especially in the simple form of acute endocarditis, the tubercle 
bacillus, the typhoid bacillus, and the anthrax bacillus have been met with. 
The colon bacillus, diphtheria bacillus, bacillus pyocyaneus, and bacillus 
of influenza have also been reported. There is no difference in the endo- 
carditis arising from these various organisms except in the degree of the 
malignant nature of the especial organism which has produced the disease, 
or in the vulnerability to infection of the individual. 

The frequent occurrence of acute endocarditis in children has been 
attributed to the greater vulnerability to bacterial action in early life. 

Acute endocarditis may be of the simple or verrucose or of the septic 
or malignant form ; this distinction, however, is based on the intensity of 
the endocarditis rather than on marked etiological differences. The 
malignant form is very rare in childhood. 

The most frequent etiological factor in simple acute endocarditis is 
acute arttcular rheumatism. It may also occur in chorea either with or 



736 PEDIATRICS. 

without a rheumatic complication. While it may occur in the course of 
any of the infectious diseases, such as influenza and diphtheria, it is most 
common in scarlet fever, pneumonia, and pleurisy, while it is not common 
in measles and varicella. The malignant form of endocarditis seems to 
occur more frequently in pneumonia than in any of the other acute in- 
fectious diseases. 

Pathology. — While the same lesions of endocarditis may be found in 
children as in adults, yet in infancy, although marked acute cardiac symp- 
toms and murmurs frequently arise, the autopsy almost invariably fails to 
show any endocardial lesions or growths. In two thousand autopsies at 
the New York Foundling Asylum, Dr. Northrup and Dr. O'Dwyer never 
found an acute inflammatory lesion, except in one case, which showed the 
lesions of acute malignant endocarditis. When the lesions of endocarditis 
are found in children, the connective tissue and the basement substance 
are principally concerned in the inflammatory process. The endocardium 
which forms the valves is that which is most frequently inflamed, but 
other portions of it are by no means exempt. In some cases there is 
swelling of the valves, which are thickened, their surfaces remaining 
smooth, the basement substance is swollen, and there is a moderate pro- 
duction of new connective-tissue cells. In other cases the growth of 
connective-tissue cells is very much more marked, the basement substance 
is broken up, and little cellular fungus-masses, called vegetations, project 
from the free surface of the endocardium (verrucous endocarditis). 

On the surface of these vegetations thrombi may be formed, and 
bacteria are sometimes present. In still other cases the cellular growth 
in some places forms vegetations, and in others degenerates, and thus 
portions of the valves are destroyed. This is acute ulcerative endocarditis, 
also called malignant endocarditis. In these cases the diseased valve and 
the thrombi contain bacteria much more frequently and in far greater 
numbers than are found in the simple benign form. This malignant form 
is evidently secondary in the course of a septic infection, and the previous 
disease of the valves favors the invasion of the infectious bacteria. In the 
simple form of acute endocarditis emboli may occur, which from their size 
usually produce mechanical disturbances alone, while in the malignant 
form the emboli are usually smaller, and, being septic, produce inflamma- 
tory rather than mechanical disturbance, giving rise to miliary abscesses 
in various parts of the body, such as the liver, kidneys, spleen, stomach, 
intestine, brain, eye, joints, and skin. Acute endocarditis may also be 
secondary to old cardiac malformations or lesions (endocarditis recurrens). 

In some cases the children recover, and the valves seem to return to 
their normal condition, while in others the valves are left permanently 
damaged. 

Simple Acute Endocarditis. — Symptoms. — The symptoms of simple 
acute endocarditis are often obscure, and in infants and young children in 
the beginning are apt to be latent. When the disease arises in connection 



ACQUIRED DISEASES OF THE HEART. 737 

with some other disease, the symptoms are especially likely to be masked 
by those of the disease which it complicates. In some cases the endocar- 
ditis develops insidiously without any additional symptoms, such as pain 
or precordial distress, and its presence is not recognized until a careful ex- 
amination of the heart detects a murmur ; in others, pronounced and even 
violent cardiac symptoms are present from the beginning. Again, the first 
evidence of an endocarditis may come from symptoms of embolism such 
as hemiplegia, hematuria, dyspnoea, cough, or localized pain, as in the 
thorax or abdomen. If the muscular tissue is involved as well as the 
endocardium, the general cardiac symptoms of dyspnoea, cyanosis, and 
palpitation are still more marked. 

When endocarditis arises in the course of acute rheumatism there 
may be nothing which would draw especial attention to the heart, but 
there are usually general symptoms of increased rapidity of the heart's 
action, with perhaps slight irregularity, restlessness, prostration, and a 
rise in the temperature, which is especially suspicious if, with this in- 
crease in the fever, there is no exacerbation of the trouble in the joints. 
Palpitation and dyspnoea are also quite frequently present. There may at 
first be no murmur, but usually after a few days a soft systolic murmur 
at the apex transmitted to the left, and later a slightly accentuated pul- 
monic second sound, may be heard. Endocarditis may with these same 
symptoms occur in the course of chorea. 

When endocarditis does not arise as a complication of some other 
disease, the symptoms at the onset, when prominent, are usually a rise 
of temperature, an accelerated and sometimes weak and irregular pulse, 
dyspnoea, palpitation, and more or less precordial distress. All these 
symptoms vary according to the extent of the lesions. Later they depend 
upon whether or not compensation has been established. In connection 
with these early symptoms, cardiac dilatation and cyanosis are very apt to 
occur. When the disease has advanced so far as to interfere with com- 
pensation, the physical signs of dilatation appear. The symptoms differ 
somewhat according as the inflammatory condition has begun in the 
valves or in the cardiac walls (Steffen). In the former case the signs 
of dilatation accompany those of valvular weakness, while in the latter 
the symptoms of dilatation come first, and are followed by the mechanical 
results of valvular insufficiency. 

In a first attack of acute endocarditis the serious symptoms connected 
with great lack of compensation which are met with when the attack 
supervenes on a previous cardiac lesion are not likely to arise. In some 
cases, however, when the individual power of cardiac resistance is slight, 
they appear early in the disease. Under these circumstances the child 
emaciates rapidly, becomes very weak and anaemic, and the cyanosis and 
dyspnoea increase. There is apt to be cough from an accompanying 
bronchial irritation, produced most frequently when there is obstruction 
at the mitral orifice. As a result of a general venous stasis, enlargement 



738 PEDIATRICS. 

of the liver, haemoptysis, and oedema of the face, legs, and arms appear. 
Children show such a wonderful recuperative power that even in these 
advanced cases under proper treatment the serious symptoms may grad- 
ually pass away, and often such complete cardiac compensation takes 
place that they are left with no symptoms of cardiac disease except a 
murmur and some hypertrophy. 

Relapses are common and there is a great tendency to recurrence. 
Embolism may take place as a late as well as an early complication. 
Anaemia is a very common symptom, especially when endocarditis ac- 
companies rheumatism. Congestion of the lungs Avith resulting haemop- 
tysis may arise when there is insufficiency of the mitral valve. When 
the valves are affected murmurs are usually present, yet sometimes when 
there are lesions of the valves murmurs cannot be detected. In endo- 
carditis murmurs are most frequently heard in the region of the mitral 
valve, and insufficiency of the mitral valve is the most common of the 
inflammatory cardiac lesions in childhood. 

Acute simple endocarditis may last for several weeks, the symptoms 
gradually subsiding or becoming chronic ; or there may be recurrent 
attacks which are especially likely to result in chronic valvular disease ; 
or acute dilatation may result with increasing symptoms of cardiac insuffi- 
ciency, dropsy, and pulmonary complications, finally ending in death. 

Diagnosis. — The diagnosis of simple acute endocarditis during life de- 
pends upon the physical signs. These signs are an increase in the area 
of cardiac dulness and a change in the sounds of the heart. The change 
in the area of cardiac dulness must be differentiated from that which 
occurs in a pericardial effusion as described on page 759. 

The change in the cardiac sounds may be produced by changes in the 
blood or by organic lesions of the valves. The differential diagnosis be- 
tween these two conditions is given on page 748, and the diagnosis of the 
especial valvular lesion is given on pages 741-745. 

Prognosis. — The prognosis of simple acute endocarditis in early life is 
comparatively favorable as to the immediate outcome, but may eventually 
become serious by the occurrence of embolism or the development of a 
malignant endocarditis. Owing to the great recuperative powers in early 
life, in many cases, especially when it is the first attack, such complete 
compensation takes place that the child practically recovers. If it is the 
walls of the heart that are affected, the heart may regain its normal size 
and position. If the valves alone, or the valves and the walls, are affected, 
recovery can still take place. The development of chronic valvular dis- 
ease is the usual termination. Death may, however, occur at the height 
of the attack, or the child may die later from exhaustion and sometimes 
suddenly from heart-failure. 

Malignant Endocarditis. — Symptoms. — The symptoms of malignant 
endocarditis are necessarily varied and indefinite, arising as they usually 
do in the course of some other disease with simply an exacerbation of 



ACQUIRED DISEASES OF THE HEART. 739 

the previous symptoms, especially of the temperature. There are usually 
the general symptoms of intermittent temperature, sweating, delirium, 
and failure in strength. Two types of the disease, septic or pysemic and 
typhoidal, are recognized. The septic type is characterized by the signs 
of septic infection, rigors, sweating, and irregular temperature, while the 
typhoidal type shows diarrhoea, dry tongue, distended and tympanitic abdo- 
men, enlargement of the spleen, profuse sweating, and a petechial efflores- 
cence on the skin. A clear distinction between the two forms, however, 
is often not marked. Cerebral symptoms may arise, and simulate menin- 
gitis and malaria. Embolic processes may produce special symptoms, 
such as paralysis, coma, bloody urine, retinal hemorrhage, peritonitis from 
infarction of the spleen, and in some cases pulmonary symptoms simu- 
lating pneumonia. Murmurs may be absent. The duration of the at- 
tack depends mostly on the disease to which it is secondary, and may 
vary from a few days to as many weeks. A marked leucocytosis is 
present. 

Diagnosis. — The diagnosis of malignant endocarditis is made from the 
simple form by the graver constitutional signs, the higher temperature, and 
the septic or typhoidal symptoms just described. From typhoid fever it 
is to be distinguished by its abrupt onset, irregular temperature, pre- 
cordial pain and distress, marked leucocytosis, and negative Widal reac- 
tion. Malaria can be eliminated by the absence of the Plasmodium ma- 
larias and the presence of leucocytosis. 

Prognosis. — The prognosis of malignant endocarditis is very grave, 
although the disease is not necessarily fatal. The heart is, however, 
permanently damaged. 

Treatment of Acute Endocarditis. — The treatment of acute endo- 
carditis during the early days of the attack is essentially rest in bed. 
When the disease is due to some specific disease, such as diphtheria, the 
specific remedy for that disease should be given at once. From the very 
beginning, however, we should endeavor to establish compensation. The 
child should be encouraged to sleep, in order that the circulation may be 
kept as quiet as possible and thus relieve the work of the disabled heart. 
The heart-beats of a young child during sleep are often reduced twenty in 
a minute, and thus sleep affords the best opportunity for compensation. 
Later the general health of the child should be carefully attended to by 
means of good food, pure air, and exercise of a mild type, never exces- 
sive. The surface circulation should be promoted by baths and gentle 
massage. Digitalis and iron are of great value, the former in aiding the 
establishment of compensation, the latter in combating the anaemia. 
When there are symptoms of heart-failure, stimulants such as alcohol, 
aromatic ammonia, and strychnine (page 470) are indicated and important. 
If at any time during the course of the disease the attacks of dyspnoea 
are excessive, nitroglycerin can be given in doses proportionate to the age 
of the child ; 0.0003 gramme {-^ grain) can be given to a child three or 



740 PEDIATRICS. 

four years old. The younger the child, the more likely it is that we shall 
have to contend with a resulting atrophic condition and anaemia. 

The treatment of the malignant form of endocarditis is essentially that 
of a septic condition, and stimulants should be used freely. 

CHRONIC ENDOCARDITIS. 

Chronic endocarditis showing sclerosis of the valve may be chronic 
from the outset, but it usually succeeds an acute endocarditis ; this occurs 
especially in the rheumatic form. 

Etiology. — The usual causes of chronic endocarditis in later life, such 
as syphilis, alcohol, gout, and strain from undue muscular exertion, are very 
seldom met with in children, acute endocarditis being the chief etiological 
condition. 

Pathology. — Although the morbid process may attack the parietal 
endocardium, it is the valvular form that is of such clinical importance 
as to become the prominent feature in chronic endocarditis. The process 
in extra-uterine life most frequently affects the aortic and mitral valves, 
the latter being especially involved in childhood. It is a slow, insidious 
process, manifested by thickening, induration, and adhesions, followed by 
a contraction of the valvular segments. Later, lime-salts are deposited in 
the valves and this results in rigidity. As the sclerotic changes increase, 
the deformity of the segments becomes greater and results either in im- 
perfect closure of the valves (valvular insufficiency), allowing a regurgitation 
of the blood, or the orifice is narrowed (valvular stenosis), causing obstruc- 
tion to the blood-current. We meet, especially in children, with lesions 
at the mitral orifice in which the valves are curled and thickened so 
that they are insufficient, although there may be no narrowing of the 
orifice. The chordae tendineae gradually become shortened. The apices 
of the papillary muscles are enlarged, the endocardium becomes thickened, 
and marked changes following the valvular lesions take place in the walls 
of the heart. These changes are represented by varying degrees of hy- 
pertrophy or dilatation according to the degree and duration of the valvu- 
lar lesions and to the extent to which compensation has been interfered 
with. In the order of their frequency the mitral valve is most often 
affected, next the aortic, then the tricuspid, and very rarely the pulmonary 
valve. It is not uncommon for the aortic and mitral valves to be affected 
together. In very rare cases all the valves may be involved. 

General Symptoms. — The symptoms of chronic endocarditis develop 
gradually, especially when compensatory hypertrophy is complete. They 
often extend over a period of many months, corresponding to the slow 
progressive nature of the valvular lesions. When there is a leakage 
through the valves or when there is obstruction to the flow of blood an 
increased amount of work is thrown upon the auricles and ventricles, and 
symptoms of hypertrophy or dilatation result which are directly in propor- 
tion to the amount of compensation which is present. The final effect, 



ACQUIRED DISEASES OF THE HEART. 741 

therefore, of all valvular lesions is a failing compensation and venous stasis 
throughout the whole body. 

In children there may be long periods when the morbid conditions do 
not increase and when, beyond occasional attacks of dyspnoea on exertion, 
other symptoms are not prominent. 

Symptoms, such as cough, epistaxis, palpitation, and anaemia, are apt to 
appear and then pass away, when for any reason the child is debilitated. 
A decided failure in compensation is liable to arise at any time from an 
attack of acute endocarditis, from over-exertion, or from the presence of 
one of the infectious diseases, such as scarlet fever or typhoid. 

As compensation fails the corresponding symptoms of a weak heart 
become more marked. There are present some, rarely all, in young chil- 
dren, of the following symptoms : increased dyspnoea, orthopncea, bron- 
chitis, dropsy, beginning in the feet, enlarged liver and spleen, ascites, renal 
congestion with albuminuria, indigestion, and, later, prominence of the 
superficial veins, clubbed fingers, and cyanosis. Emaciation is a marked 
symptom. There may be at any time during the course of the disease 
cerebral symptoms such as fainting and dizziness, and sometimes headache. 
These symptoms, even when extreme, may all pass away, and then at 
varying periods of months or years return. Death may take place from 
sudden paralysis of the heart or as a result of the additional tax on the 
heart from some intercurrent disease, such as pneumonia or nephritis. 
Embolism, with its resulting paralysis or oedema of the lungs, may hasten 
the fatal result. 

In connection with these symptoms certain physical signs of the heart 
itself are present which correspond to the especial valvular lesions which 
are present. 

Mitral Insufficiency. — Incompetency of the mitral valve with regurgi- 
tation is the most common of all the valvular lesions, and in most cases 
is caused by rheumatism. It is also especially met with in chorea. Before 
compensation has taken place, the lesion is represented by a systolic 
murmur most marked at the apex, synchronous with the impulse and 
with the first sound, which it may replace, and transmitted into the axilla 
and back. When compensation has taken place there is an accentuated 
pulmonic second sound and an increased area of cardiac dulness, corre- 
sponding at first to enlargement of the left auricle and right ventricle and 
later of the whole heart. In this latter condition there is not only an 
increase in the breadth of the heart, but also in its length, the apex being 
depressed and carried in varied degrees to the left of the mammillary line. 
There may be bulging of the precordia. The aortic second sound is 
diminished. The pulse is diminished in volume and tension. 

As compensation fails the general symptoms of a weak heart appear, 
and dilatation predominates over the hypertrophy with the sequence of 
symptoms already described. 

Mitral Stenosis. — Stenosis of the mitral valve is usually the result 



742 PEDIATRICS. 

of chronic endocarditis. It develops slowly and is often a later stage of 
the same process which has earlier produced mitral regurgitation. It 
occurs most commonly in girls, and many cases are associated with 
tuberculosis of the lungs. 

In the early part of the disease there is little or no increase in the 
cardiac dulness, but later the cardiac area is increased in breadth and cor- 
responds to an enlarged left auricle and right ventricle. A sign which 
may be said to be characteristic of mitral stenosis is a thrill, which on 
palpation gives rise to a purring sensation, felt at the apex of the heart, 
just before and up to the time of the systole, when it ceases sharply. As 
in mitral regurgitation, there may be bulging in the precordial region, 
especially to the left of the sternum and within the mammillary line. The 
impulse is both seen and felt rather higher in the vertical line than is 
normal, and is due to the impulse of the conus arteriosus of the right 
ventricle. A presystolic murmur, rough and purring in quality, is heard 
in the mitral area over a rather limited space, and is not markedly trans- 
mitted. It begins shortly after the end of diastole and increases with a 
crescendo until systole begins, when it ceases abruptly with a very sharp 
first sound. The thrill can sometimes be felt when no murmur is heard, 
and can be transmitted into the axilla, while the murmur is only heard in 
the mitral area ; in some cases, however, the murmur is transmitted into 
the axilla. The second sound is frequently reduplicated, and this is an 
important diagnostic sign, as it may be heard in some cases in which the 
murmur is absent. Irregularity in force and rhythm may occur at any 
stage. 

The pulmonic second sound is accentuated, may be reduplicated, and 
may be transmitted a considerable distance to the left. In uncomplicated 
cases there is usually no murmur heard in the aortic area. In the later 
stages of the disease, corresponding to marked dilatation of the right 
ventricle, tricuspid regurgitation develops and the murmur may disappear. 
The sharp first sound remains, and, with prolongation of diastole and 
great cardiac irregularity, is of much aid in the diagnosis at this stage. 
When in conjunction with a reduplicated second sound, it suggests mitral 
stenosis, which may be masked by the prominence of the signs of mitral 
regurgitation, which is so commonly associated with mitral stenosis. 

It is rather characteristic of mitral stenosis that, although the pulse 
may be markedly irregular, the general circulation remains good for long 
periods. Embolism is a very common complication, even more so than 
in lesions of the other valves. Haemoptysis is also apt to occur. 

Finally, compensation fails and the symptoms are the same as in mitral 
insufficiency Avith cardiac dilatation. Dropsy in many cases is absent. 
Hepatic enlargement and ascites are common. The increased area of 
cardiac dulness is often masked by the increased size of the lungs. 

The prognosis of pulmonary and pleural affections arising in the course 
of a mitral stenosis is especially bad. 



ACQUIRED DISEASES OF THE HEART. 743 

xV presystolic murmur at the apex may be heard in some cases of 
aortic regurgitation, but the murmur may be considered to arise from 
mitral stenosis if with absence of a predominating hypertrophy of the left 
ventricle there are the signs of pulmonary congestion, accentuation of the 
pulmonic second sound, and a sharp mitral first sound. Tricuspid ob- 
struction is almost impossible to differentiate from mitral stenosis, but 
is exceedingly rare. Following an attack of pericarditis a murmur may 
be heard which closely simulates mitral stenosis, but is differentiated by 
absence of the sharp first sound at the apex and the other signs of peri- 
carditis. 

Aortic Insufficiency. — Lesions of the aortic orifice are rare in child- 
hood, as rheumatism, the most frequent cause of endocarditis in children, 
in almost all cases attacks the mitral valves. Aortic disease may there- 
fore be said to belong essentially to a later period of life, and, when it 
does occur in early life, to be associated almost invariably with some 
other valvular lesion, usually the mitral. In most cases there is a thick- 
ening and shortening of the cusps, causing a regurgitation of the blood 
from the aorta into the left ventricle during diastole. As a result of the 
increased amount of work thrown on the left ventricle dilatation and 
hypertrophy occur, producing greater ventricular enlargement than any 
other form of valvular disease. As a result there is marked heaving, 
throbbing, and often bulging in the precordia. There is great increase of 
the cardiac dulness, especially to the left and downward. 

Aortic insufficiency is shown by a rather faint murmur coincident with 
or replacing the second aortic sound. The maximum intensity of this 
murmur seems to vary in different cases. It may be loudest in the aortic 
area, but is most common in the midsternal region, especially on the left 
side of the sternum at about the level of the fourth left costal cartilage. 
The murmur in some cases is also heard distinctly near the apex of the 
heart, and less frequently its maximum intensity may be at the second or 
third left costal cartilage or over the ensiform cartilage. 

Although in a certain number of cases the murmur may be transmitted 
into the axilla and even into the back, as a rule the transmission is limited 
to the precordia, although it may extend in all directions, but especially 
downward towards the apex. The aortic sounds, and sometimes the 
murmur, may be transmitted into the carotid and subclavian arteries. 
The carotid arteries may show evident pulsation, and there is the char- 
acteristic Corrigan pulse. The first sound of the heart at the apex is 
prolonged. The pulmonic second sound is not accentuated. The gen- 
eral symptoms usually come on slowly, and are characterized at first by 
dyspnoea, headache, and other signs of cerebral congestion. 

Compensation may last for long periods, but when it fails symptoms 
of faintness, precordial pain, angina pectoris, and sometimes, although 
rarely, dropsy and cyanosis appear, these latter two symptoms usually 
occurring when an associated relative insufficiency of the mitral orifice 



744 PEDIATRICS. 

has taken place. Death follows quite frequently from cardiac paralysis, 
cerebral hemorrhage, or arterial embolism before insufficiency occurs. 

Aortic Stenosis. — Narrowing of the aortic orifice is rare, and is much 
less frequent than the other valvular lesions of the left side of the heart. 
It is very apt to be associated with aortic insufficiency. As a result of 
this lesion there is dilatation and hypertrophy of the left ventricle ; the 
hypertrophy, however, being markedly predominant. 

Aortic stenosis is represented by a loud, late, systolic murmur, heard 
with greatest intensity in the second right intercostal space and transmitted 
upward to the carotids. The murmur is also transmitted widely all over 
the chest. The aortic first sound is usually obliterated, the aortic second 
is much weakened, and, if there is also an insufficiency of the aortic valves, 
a diastolic murmur is heard. 

The pulse is small, slow, and wavy, unless modified by insufficiency. 
Usually a thrill is heard and felt most distinctly in the aortic area and 
transmitted to the carotids. There are fewer general symptoms in this 
lesion of the heart than in any other, until the compensation, which is 
usually complete, gives way. When, however, compensation fails, the 
same general symptoms which have been described under aortic insuffi- 
ciency occur. Eventually insufficiency of the mitral valve develops, with 
its concomitant signs and symptoms. 

It is to be remembered that a systolic murmur in the aortic area is 
not distinctive of aortic stenosis, and also that an aortic systolic murmur 
may occasionally be heard with greatest intensity at the apex and be 
mistaken for that of mitral regurgitation. Other murmurs which may 
occur in the aortic area, and which are especially to be differentiated, are 
the functional murmurs of unusual distribution and the murmur of the 
very rare pulmonary stenosis. A patent ductus arteriosus may also pro- 
duce a systolic murmur in the aortic area. 

Tricuspid Insufficiency. — Endocarditis of the tricuspid valve acquired 
in extra-uterine life is very rare, and when it occurs is associated with 
lesions of the mitral or aortic valves or of both. Relative insufficiency 
of the tricuspid valve from stretching of the orifice occurs commonly as a 
result of mitral insufficiency and of such pulmonary diseases as emphysema 
and chronic bronchitis, which cause obstruction to the pulmonary circulation. 

The chief signs of the regurgitation of the blood from the right ven- 
tricle into the right auricle are as follows. There is a wave of trans- 
mission which gives a systolic pulsation of the jugular veins, causing them 
to stand out prominently, especially on the right side. This systolic 
pulsation may also occur, although less frequently, in the liver from con- 
gestion of the branches of the hepatic vein. There is a systolic murmur, 
rather soft and low, heard at the lower part of the sternum, the maxi- 
mum intensity being near the sternal junction of the fifth or sixth left 
costal cartilage, usually not distributed widely, but in some cases trans- 
mitted to the right as far as the axilla. The pulmonic second sound is, 



ACQUIRED DISEASES OF THE HEART. 745 

as a rule, not increased. The area of cardiac dulness corresponds to that 
of dilatation of the right ventricle, but is usually moderate, and extends 
to the right as well as to the left and downward. Cyanosis is especially 
pronounced. 

It must be remembered that tricuspid insufficiency is in most cases 
exceedingly difficult to diagnosticate : in some cases there are no physical 
signs recognizable during life ; in many cases the signs are those of the 
associated mitral lesion, and the pulmonic second sound remains strong 
even when a tricuspid lesion is found to be present. 

Tricuspid Stenosis. — Tricuspid stenosis as an acquired disease in 
extra-uterine life is so very rare in children, so uniformly of congenital 
origin, and so very difficult of diagnosis, that it need only be referred to as 
a possible condition. Its diagnosis would depend on an enlarged right 
auricle, a presystolic murmur loudest near the ensiform cartilage, and 
venous congestion as in tricuspid insufficiency. Its frequent association 
with aortic and mitral stenosis makes its recognition, however, during life 
almost impossible. 

Pulmonary Insufficiency and Stenosis. — Although organic disease 
of the pulmonary valve may result from foetal endocarditis, it is rarely 
acquired in extra-uterine life, and then only in septic processes. 

The diastolic murmur of pulmonary insufficiency should be distin- 
guished from that of aortic insufficiency by not being transmitted to the 
carotids, by an hypertrophied right ventricle, by sharp accentuation of 
the pulmonic second sound, by evidence of septic embolism in the lungs, 
and by the absence of the Corrigan pulse. 

When there is pulmonary stenosis the lesion is so universally of con- 
genital origin that its diagnosis can be referred to what has already been 
described under congenital diseases of the heart. 

Diagnosis. — The diagnosis of chronic valvular disease, when a single 
lesion of regurgitation or stenosis is present without an association with 
lesions of other valves, is made by the physical signs of the individual 
affection which have just been described. Combined valvular lesions 
are, however, exceedingly common, and render the diagnosis much more 
difficult. The diagnosis depends upon the character of the murmurs, 
upon the degree of dilatation and hypertrophy of the auricles and ven- 
tricles, and upon the general symptoms referable to the circulation and 
respiration. Too much importance must not be attached to the pres- 
ence or sound of murmurs alone, as they may be functional. The dis- 
tinction between organic and functional murmurs is given on page 748. 

Prognosis. — Although children often show a wonderful power of re- 
cuperation, yet, unless the lesion is very slight, it can never be completely 
recovered from. The dangers from embolism or a recurrent endocarditis 
must always be borne in mind as increasing the gravity of the prognosis, 
but so long as compensation is efficient the prognosis is good, although 
murmurs of all kinds may be present. 



746 PEDIATRICS. 

Many of the influences which make the prognosis in later life bad, 
such as disease of the coronary arteries, are rare in early life. The mitral 
and aortic valves which are most commonly attacked in the acquired en- 
docarditis of children are the ones in which compensation is most readily 
attained. In young children, however, the prognosis, on the whole, is 
unfavorable in chronic valvular lesions. 

The nutrition of the rapidly growing heart is easily affected, and dila- 
tation develops rapidly. Recurrent attacks of rheumatism are very 
common in children, and each attack increases the gravity of the prog- 
nosis. In like manner the onset of one of the acute infectious diseases 
means an exceptionally bad prognosis in children in whom valvular dis- 
ease is present. 

Extensive pericardial adhesions, insufficient or improper food, and 
lack of supervision of the amount of exercise greatly increase the risks of 
disturbing the compensation of the heart. 

Treatment of Chronic Endocarditis. — The indications for treatment 
of chronic endocarditis depend less upon the character of the lesion than 
upon the degree of compensation which is present. When compensation 
is established and withstands the ordinary demands of life, hygienic and 
prophylactic measures alone are necessary. As compensation fails, active 
treatment is called for, and is directly proportionate to the severity of the 
symptoms. 

Simple hypertrophy of the heart, therefore, Avhether from endocardial 
causes, as from chronic valvular lesions, or from exocardial conditions, 
does not require the use of drugs. The regulation of the habits of life 
are of the first importance. Great care should be taken not to overtax 
any of the functions of the body. The digestive, nervous, and muscular 
systems should be kept well within the limits of fatigue. The diet should 
be carefully regulated according to the age and digestion of the child. 
Nervous strain from over-study and emotional excitement should be care- 
fully guarded against. Out-of-door life and moderate exercise should be 
encouraged, but the more vigorous forms of athletic sports should be pro- 
hibited. Each case must be judged by itself as to the amount of muscu- 
lar work which is permissible, and this can be determined only by begin- 
ning with the mildest forms of exercise and cautiously increasing the 
amount. It is often desirable to insist upon absolute rest in bed or on a 
lounge for an hour or two in the middle of each day. 

With the advent of the early symptoms of failing compensation the 
cessation of all exercise and the use of appropriate doses of nux vomica 
and iron for a few weeks may restore the lost compensation. If the 
symptoms are persistent, the nux vomica should be supplanted by small 
doses of the tincture of digitalis. A change of climate is sometimes to 
be recommended in those cases in which the failure of compensation is 
slowly progressive. 

Acute dilatation may come on suddenly with but few premonitory 



ACQUIRED DISEASES OF THE HEART. 747 

symptoms. The treatment is then absolute rest in bed and active stimu- 
lation by the use of strychnine and digitalis in doses as recommended on 
page 470. Brandy or aromatic spirits of ammonia are useful to bridge 
over a crisis, and not infrequently small doses of morphine, guarded with 
atropine, given subcutaneously, can advantageously precede the use of 
the cardiac stimulants. Digitalis and strychnine are, however, the drugs 
on which most reliance can be placed in all the stages of a broken com- 
pensation. As the cardiac weakness increases, special symptoms arise 
which demand special treatment. 

Dyspnoea, — When the dyspnoea becomes troublesome, the child should 
be propped up by means of pillows or a bed-rest into a semi-upright 
position. The cause of the dyspnoea should be determined if possible, 
remembering that it may be due to -flatulency, hydrothorax, hydroperi- 
cardium, ascites, or oedema of the lungs. If it is of gastric origin, the 
digestive disturbance should receive appropriate treatment, both for the 
relief of the immediate symptoms and the prevention of its recurrence by 
the proper change in the diet. Hydrothorax, if present, may require re- 
peated tapping, but this is of rare occurrence. The oedema of the lung, 
as evidenced by the dyspnoea, cough, and physical signs, is best controlled 
by stimulation of the heart rather than by treatment directed to the lungs. 
When the dyspnoea is apparently due to high blood-tension, the use of 
nitroglycerin, in doses such as are prescribed on page 470, will often 
meet the requirements. 

Vomiting. — Vomiting is often a difficult symptom to control. If it is 
due to venous stasis, digitalis will often act well, but the vomiting may in 
itself be an early indication of the over-action of digitalis. If the vomit- 
ing is persistent, it may be necessary to omit all food by the stomach. 
Cracked ice in some simple charged water, or in champagne, or in milk 
and lime-water, can be used until stronger food is tolerated. 

Dropsy. — The successful treatment of dropsy depends upon the re- 
cuperative power which remains in the heart. Digitalis is of the utmost use, 
and should be given in sufficiently large doses to produce a decided effect, 
but with careful attention to its physiological action. Its diuretic proper- 
ties may be increased at times by giving it with small doses of calomel 
and caffeine, providing the kidneys show the evidence only of passive 
congestion. Saline cathartics can be given to diminish the oedema by de- 
pletion. It is often desirable to promote catharsis and diuresis on alter- 
nate days. If ascites or hydrothorax is excessive, the fluid should be 
aspirated at once, as delay may prove serious. The quantity of urine 
should be carefully noted when digitalis is being given. An increase in 
the quantity should follow its administration. When the urine diminishes 
steadily in spite of the digitalis, we should watch carefully for other 
symptoms of the cumulative action of the drug. Diuretin in doses of 
0.3 to 0.6 gramme (5 to 10 grains) is a valuable diuretic in all forms of 
cardiac dropsy, and may be given alone or with digitalis. 



748 PEDIATRICS. 

Nervous Symptoms. — The nervous symptoms of restlessness and in- 
somnia may, if moderate in degree, be controlled by trional or the bro- 
mides, 0.12 to 0.3 gramme (2 to 5 grains) ; more frequently they require 
the use of morphine combined with atropine, which are the most effective 
remedies we have, but require good judgment in their use. 

Finally, it is of the greatest importance that a child with a chronic 
valvular lesion of the heart should be kept under medical supervision 
even during the intervals of complete compensation. By doing this we 
are frequently able to detect changes in the condition of the heart before 
the mother herself becomes aware of them, and by attention to the prin- 
ciples already outlined we may often avert the serious consequences which 
follow neglect of treatment. 

FUNCTIONAL DISEASES OF THE HEART. 

By functional disease of the heart we mean that there are no patho- 
logical conditions present beyond a weakness of the cardiac muscles and 
possibly, in some cases, a slight degree of dilatation of the cavities. It is 
a condition, therefore, represented by symptoms rather than by physical 
signs, with the exception that in many cases cardiac murmurs are present. 
It is rare to meet with functional cardiac disturbances before the middle 
period of childhood, but they increase in frequency as puberty is ap- 
proached. 

Etiology. — Functional cardiac disturbance may occur in the course of 
such neuroses as exophthalmic goitre. Again, it may arise from poor food 
and hygiene, from a lack of sufficient out-of-door exercise, and from over- 
strain in school life, leading to malnutrition Avith nervous exhaustion. It 
may also result from the use of such cardiac irritants as tea and coffee, 
and may follow or occur in the course of any of the acute diseases. The 
various forms of anaemia may produce functional murmurs, known as 
hcemic murmurs. 

Symptoms. — The chief symptoms are palpitation, a weakened, irregular 
pulse, attacks of dyspnoea and fainting, and cardiac murmurs. These 
attacks occur in paroxysms and are not associated with the physical 
signs of organic cardiac disease. 

Of especial interest are the cardiac murmurs of functional origin, as 
they simulate closely and must be differentiated from organic murmurs, 
whether congenital or acquired. These functional or, as they are some- 
times called, haemic murmurs are variable in character according to the 
position of the child, and may sometimes be intensified by the pressure of 
the stethoscope. 

According to Jacobi, Steffen, and Hochsinger they may also be caused 
by the irritation resulting from deformity of the thorax such as occurs in 
rhachitis. . 

Diagnosis. — In the great majority of cases functional murmurs are sys- 
tolic, soft, though they may be very loud, and are heard best in the pul- 



ACQUIRED DISEASES OF THE HEART. 749 

monic area. They are apt to be associated with anaemia, are evanescent, 
are not connected with cardiac enlargement, and are not accompanied by 
an accentuated pulmonic second sound or by general systemic venous 
engorgement. 

While these functional murmurs may be transmitted in all directions, 
and are often associated with loud bruits in the vessels of the neck, yet, 
as a rule, they do not show their maximum intensity at the heart's apex and 
are not transmitted distinctly to the axilla and back. The systolic mur- 
murs heard occasionally over the anterior fontanelle in infants are probably 
arterial. 

In contradistinction to functional murmurs, organic murmurs are usually 
rougher and more musical, are distinctly transmitted to the great vessels 
of the neck or to the axilla and back, may be heard with maximum in- 
tensity over any part of the cardiac area corresponding to the various 
valves, are rarely loudest in the pulmonic area, and are usually associated 
with an enlarged cardiac area, accentuated pulmonic second sound, and in 
many cases with general signs of systemic stasis, such as cough, haemop- 
tysis, oedema of the lungs and extremities, ascites, and cyanosis. 

Prognosis. — The prognosis in the cases in which there is no organic 
disease of other organs, or when the disease in which they occur is be- 
nign, is exceedingly good, provided that the appropriate treatment is rigidly 
carried out. 

Treatment. — During the attack mild stimulants, such as aromatic spirits 
of ammonia, should be given, and if there is a strong nervous element the 
bromides. In prolonged attacks digitalis in small doses is indicated, and 
in some cases strychnine. 

When a cause can be detected, such as anaemia, it should be treated 
with iron or arsenic. When no especial cause can be found, all cardiac 
irritants should be avoided and careful directions given as to study, exer- 
cise, diet, and general hygiene. 

The following ease was one of primary malignant endocarditis with 
secondary infection of the pericardium, mediastinum, veins, lungs, pleurae, 
and spleen. 

A boy, four years old, was attacked one month previously with fever, thirst, and 
pain in his knees. Later his feet became painful and swollen, and other joints were 
successively involved. He complained of pain in the back of his neck and along his 
spine. One week before entering the hospital he began to have moderate but inces- 
sant choreic movements, and showed much incoordination of mastication and articu- 
lation. 

A physical examination showed the lungs to be normal, the area of cardiac dul- 
ness somewhat increased to the left of the mammillary line, and a systolic murmur at 
the apex, transmitted into the axilla and back. On the following day a pericardial 
friction-sound was heard just above the left nipple, accompanied by precordial pain. 
Two weeks later the choreic symptoms disappeared, and the temperature became 
normal. The area of cardiac dulness did not extend under the sternum, but was 
found to correspond to the impulse of the heart, which was 1.4 cm. (£ inch) outside 



750 PEDIATRICS. 

of the left mammillary line. During the last week of its life the child became very 
weak, had marked dyspnoea, and showed signs of effusion in the right pleural cavity, 
but presented no other symptoms. 

The post-mortem examination showed that both pleural cavities contained consid- 
erable blood-stained fluid, in some places there were adhesions of the parietal and 
visceral layers, in others there was slight fibrinous exudation over the surfaces of the 
lungs. On section both lungs showed congestion and areas of broncho-pneumonia. The 
anterior mediastinum was injected, and some of the mediastinal glands were enlarged. 
The parietal layers of the pericardium and pleurae were adherent and thickened. The 
heart was enlarged, and in places the myocardium was distinctly soft and pale. Along 
the free border of the right auriculo-ventricular valve there were a few fresh vegeta- 
tions. The left side of the heart was dilated. The edge of the mitral valve was thick- 
ened and eroded. Small, whitish points could be seen beneath the endocardium, both 
on the walls and on the papillary muscles. The aortic valves showed a few fibrinous 
deposits at the edges of contact. The coronary arteries were normal. 

The spleen and lymph-glands were enlarged and soft. The liver showed congestion. 
In the left jugular vein was found an adherent thrombus which extended down into 
the subclavian vein, the innominate vein, and the superior vena cava, completely 
obliterating them. 

Microscopic examinations showed the infection to be due to streptococci and the 
vegetations on the mitral valve to be distinctly verrucose. Pure cultures of streptococci 
were obtained from the lungs, pericardium, bronchial lymph-glands, and spleen ; the 
other organs were sterile. 

Dr. Councilman, who performed the autopsy, considered the endocarditis primary 
and of the malignant type, with a secondary infection of the lung. The mode of in- 
fection was probably from the heart to the pericardium, thence to the mediastinum, 
with thrombosis of the veins, from which the infection was carried to the lungs, setting- 
up a broncho-pneumonia, which in its gross and microscopic appearances differed 
from the ordinary broncho-pneumonia of infants. 

The next case illustrates simple acute endocarditis, followed by dila- 
tation of the heart and loss of compensation. 





Fig. 153. 






:', 








f- m^±_ 








•» 






m 




; .>> ' *<-? 


™"^^^J 


*•>*»*£ 


■ .. ■ 






■ .:s-i 



Acute endocarditis. Mitral insufficiency. Lack of compensation. Orthopnoea. Female, 9 years old. 

The child was nine years old, and although she had always been delicate she had 
never had any especial disease until two weeks previously, when she was attacked 



ACQUIRED DISEASES OF THE HEART. 751 

with fever, palpitation, cough, and a rapid, irregular pulse. On entering the hospital 
she was cyanotic, the face and extremities were cold, and there was considerable promi- 
nence over the cardiac region. The resonance of the lungs was normal, but there 
were a few moist rales at both bases. The impulse of the heart was in the fifth left 
interspace, 1.4 cm. (h inch) outside of the mammillary line, and there was a marked 
thrill with a systolic murmur transmitted into the axilla and heard distinctly in the 
back. The liver was slightly enlarged. The temperature during the acute inflamma- 
tory stage of the endocarditis was moderately elevated, reaching 38.8° C. (102° F.) on 
the fourth day, and gradually subsiding. 

The impulse of the heart was scarcely perceptible. The area of cardiac dulness 
extended to the right edge of the sternum, and slightly beyond the right sternal line 
beneath the third intercostal space. 

The case illustrates an attack of acute endocarditis, either primary in character or 
more probably ingrafted upon a chronic endocarditis, which had never given rise to 
symptoms, as the limits of compensation had never before been disturbed. The acute 
inflammatory stage passed ; dilatation took place, and there was marked failure of 
compensation, shown by the feeble impulse of the heart, the weak and fluttering 
pulse, the cold and blue extremities, the orthopncea, and the tendency to oedema of 
the face, legs, and feet. Fig. 153 represents the position which the child assumed on 
her right side, supporting herself with her arms, and shows her anxious expression as 
she endeavored to keep herself in a position in which she could breathe easily. 

The following case illustrates the condition of pure mitral stenosis, 
with periods of broken compensation alternating with periods of re- 
established compensation : 

The boy, who was eleven years old, had measles when he was an infant, diph- 
theria when he was three years old, and pertussis when he was four years old. He 
had always been well until he was nine and a half years old, when, after indefinite 
pains in his joints, accompanied by no swelling and not sufficiently severe to confine 
him to bed, he began to have dyspnoea on exertion, and cardiac pain, cough, cyanosis, 
and considerable loss of weight. An examination of the heart showed the area of 
absolute dulness to be decidedly increased to the left. A loud presystolic murmur was 
heard at the apex, limited in its extent and accompanied by a thrill and a sharp first 
sound. There was no systolic murmur and no oedema. The physical examination 
showed nothing else of significance. 

In the course of two months' treatment compensation was established, but the 
boy returned to the hospital from time to time with the same symptoms which have 
been described. 

In the next case, in contrast to the one just given, we see the symp- 
toms of a mitral stenosis combined with mitral insufficiency. 

The child was a girl of thirteen years. When eleven years of age she had an 
attack of rheumatism followed by dyspnoea on exertion, and at times oedema of the 
feet. A week before I saw her she was taken with pain in the region of the heart, 
so severe that she could not sleep. On entrance to the hospital her temperature was 
38.5° C, (101.2° F.), her pulse 104, and her respirations 65. The physical exami- 
nation showed the apex-beat to be in the fifth interspace in the mammillary line. The 
area of cardiac dulness was enlarged, extending to the upper border of the third rib 
and. about 5.3 cm. (2 inches) to the left of the mammillary line, and about a finger's, 
breadth to the right of the right border of the sternum. A presystolic murmur was 
heard at the apex and was confined to a limited area, while a systolic murmur, also 



752 PEDIATRICS. 

heard at the apex, was transmitted to the axilla and back. The pulmonic second 
sound was accentuated. In this respect the physical signs were negative, as, in spite 
of the marked hypertrophy and dilatation of the heart, compensation of the right heart 
was sufficient to prevent the results of venous stasis. 

Four weeks later, after being treated by complete rest in bed, the cardiac symptoms 
almost entirely disappeared, the area of cardiac dulness was much diminished, the 
murmurs were less distinct, and the child left the hospital much improved. 

The next case (Fig. 154), a boy, ten years old, is interesting as illus- 
trating several characteristics of cardiac disease in early life. 

When eight years old he entered the hospital with marked oedema of the face, 
body, and limbs, ascites, a slight amount of fluid in both pleural cavities, and oedema 
of the lungs. There was no definite history of rheumatism nor any other cause for the 
cardiac disease which was causing these symptoms, and which had apparently de- 
veloped insidiously, although if he had been under closer observation a definite 
period of onset would probably have been discovered. The impulse of the heart was 
found to be 1.4 cm. (J inch) outside of the mam miliary line in the fifth left interspace. 
The area of cardiac dulness was somewhat increased. There was a loud systolic 
murmur at the cardiac apex transmitted to the axilla. The pulmonic second sound 
was much accentuated. Fig. 155 was taken at that time, and shows the marked oedema 
of the legs and the much distended abdomen. He was treated by complete rest in bed 
for five weeks, and in the beginning digitalis was administered until the urine, which 
was lessened in quantity, had increased and the oedema of the lungs had disappeared. 
On entering the hospital the ascites was removed by paracentesis abdominis. Under 
this treatment the child rapidly improved, the general oedema disappeared, the liver 
returned to its normal size, the area of cardiac dulness was markedly decreased, the 
cardiac murmur became less marked, and six weeks from the time when he entered 
the hospital complete compensation was established and he left the hospital seemingly 
perfectly well. 

After leaving the hospital the boy was reported to have been very well, except that 
he could not play or work hard. Two weeks before his second entrance he was attacked 
with fever, precordial distress, and cardiac pain ; later he began to have oedema of the 
feet and dyspnoea. From that time he grew progressively worse, and his case illustrates 
a fresh attack of endocarditis supervening on an old chronic endocarditis (endocarditis 
recurrens) and resulting in a disturbance of the previous compensation. He had or- 
thopnoea to such an extent that he was unable to lie down in bed, and had to be con- 
tinually watched by a nurse, as he frequently had attacks of excessive paroxysmal 
dyspnoea which were liable to prove fatal. There was cyanosis of the lips and hands 
and marked general oedema. The skin of the nose and extremities was cold. The 
impulse of the heart was felt in the sixth left interspace 2.8 cm. (1 inch) beyond the 
mammillary line. The area of cardiac dulness extended beneath the sternum, and at 
the third intercostal space extended 1.4 cm. (J inch) to the right of the sternum, 
thence upward in a curved line across the upper part of the sternum to the second rib, 
and then, keeping outside of the mammillary line, descended" and joined the point of 
cardiac impulse. There was a loud systolic murmur, heard most distinctly at the apex, 
but transmitted over the whole cardiac area and through the axilla to the back. The 
pulmonic second sound was accentuated. The aortic sounds were weak. There 
were numerous moist rales heard in all parts of the lungs. The percussion of the 
lungs was resonant everywhere except in the lower parts, where there seemed to be a 
slight amount of fluid in both pleural cavities. The liver was enlarged so that it ex- 
tended 7.8 cm. (3 inches) below the margin of the ribs. Ascites was present, the fluid 
rising to about the line of the umbilicus. The spleen was normal in size. The child 



Fig. 154. 




Chronic recurrent endocarditis. Mitral insufficiency. Disturbance of compensation. Dilated heart. 
Enlarged liver. (Edema of lungs. Ascites. Male, 10 years old. 



Fig. 155. 




Chronic endocarditis. Mitralinsufficiency. General oedema and ascites. (Before treatment.) 



ACQUIRED DISEASES OF THE HEART. 



753 



was passing only a small amount of urine, which contained a trace of albumin. The 
cardiac and hepatic areas of duiness and the upper border of the ascites have been 
marked by black lines, the margin of the ribs by broken lines, the point of cardiac 
impulse by a black ring, and the cedematous rales in the chest by smaller black rings. 
The prognosis in this case, although very serious, as he was liable to die suddenly at 
any time if extra blood-pressure should be brought to bear upon the dilated and crip- 
pled heart, was not entirely unfavorable, as he had previously shown such great powers 
of compensation and recuperation. As there was no great distention of the abdomen, 
the ascites was not removed by paracentesis. He was given infusion of digitalis, 3.75 
c.c. (1 drachm), every three hours, and diuretin, 0.36 gramme (6 grains), once in six 
hours as a diuretic. His diet was milk. 

Within forty-eight hours rapid relief was obtained from the urgent symptoms, and 
at the end of three weeks the oedema of the lungs, the general oedema, and the ascites 
had disappeared entirely. The urine became normal in quantity and free from albu- 
min. One week later he was well enough to be out of bed for an hoar each day, but 
at that time the heart and liver were still enlarged, as shown in Fig. 156. 



Fig. 156. 



Fig. 15 





Chronic endocarditis. Mitral insufficiency. 
Returning compensation. Enlarged liver. En- 
larged heart. 



Chronic endocarditis. Mitral insufficiency. 
Broken line indicates enlarged heart. Black line 
indicates area of cardiac duiness with returned 
and complete compensation. 



Some weeks later the liver regained its normal size, and still later the cardiac area 
of duiness was found to be much reduced and in the vertical line almost normal. Fig. 
157 shows the enlarged heart, which persisted longer than the enlarged liver, and is 
represented by a broken line ; the area of duiness of the heart as it appeared when 
he left the hospital is shown by a black curved line. 

48 



754 PEDIATRICS. 

DISEASES OF THE PERICARDIUM. 
The relations of the infant's pericardium, so far as I have been able 
to determine by the dissection of sixteen infants of different ages, does 
not differ from those of the adult. The amount of fluid which normally 
occurs in an infant's pericardium, although of variable quantity, is probably 
under 5 c.c. Hydropericardium, pneumopericardium, and hsemopericar- 
dium are so very rare that they need merely be referred to. 

ACUTE PERICARDITIS. 

Etiology.- — Acute pericarditis may occur at any period, but the earlier 
the age the less often is it met with. It has been found in the foetus and 
in the new-born. It is generally the result of an infective process, which 
may be primary or secondary. It may arise also as a result of direct 
extension of an inflammation from the pleurae, mediastinum, and adja- 
cent tissues. 

Various bacteria have been demonstrated in the inflammatory prod- 
ucts of pericarditis and in the pericardium itself, although they are not 
always connected in a specific manner with the disease. Different kinds 
of streptococci and staphylococci are found. The pneumococcus 
frequently occurs in cases following pneumonia, and is also found inde- 
pendently. Tubercle bacilli have been demonstrated in tubercular peri- 
carditis, and the pericardium shows an especial tendency to the invasion 
of this bacillus following tuberculosis of the pleura. Tuberculosis as a 
primary disease is even more rare in the child than in the adult. 

In the new-born, pericarditis may be the result of a septic condition 
following infection of the cord. At times it follows periostitis and ostitis 
in young children, here also probably being associated with septic infec- 
tion. Traumatism may also be a cause of pericarditis. Rheumatism, 
especially after the third or fourth year of life, gives rise to as much peri- 
endocardial disease as at a later period. The inflammatory lesions may 
arise before the rheumatism has appeared elsewhere, and the intensity of 
the arthritic pain and the number of joints affected do not correspond to, 
or rather do not influence, the frequency of the pericardial complication. 
Inflammation of the pericardium is also frequently associated with pneu- 
monia. It may be secondary to any of the eruptive fevers, but occurs 
most frequently as a complication of scarlet fever. When it occurs in 
this latter disease it appears usually in the second or third week of the 
attack. 

Pathology. — Pericarditis may be circumscribed or diffuse, and there 
appears to be no essential difference between the pathological conditions 
affecting the pericardium in early life and those which occur later. The 
pericarditis sicca of the adult is comparatively unusual in the child, in 
whom, as a rule, an exudation of greater or less extent almost always 
takes place. The exudation may be sero-fibrinous, hemorrhagic, or puru- 



DISEASES OF THE PERICARDIUM. 755 

lent. Not only is the tendency to exudation in the child greater than in 
the adult, but its formation is characterized by greater rapidity and is 
more likely to be purulent. A pericardial exudation tinged with blood is 
not uncommon in early life, and is not necessarily so significant of tuber- 
culosis as is a pronounced hemorrhagic exudation. 

Acute Plastic or Dry Pericarditis. — Symptoms. — The symptoms of 
acute plastic or dry pericarditis are often so mild as to be overlooked. 
There may be slight precordial pain and pyrexia. The characteristic physi- 
cal signs are represented by a double to-and-fro murmur, which is not ex- 
actly synchronous with systole and diastole, is more superficial than an 
endocardial murmur, and is of a rubbing or grating character. The 
sound is localized in a small area, is not transmitted as in endocardial 
murmurs, and does not replace the heart-sounds. The murmur is at 
times intensified by pressure with the stethoscope. These signs, however, 
are of temporary duration, as a rule, as the exudation of fibrin is soon 
followed by that of fluid. In many cases in early life friction-sounds 
and endocardial murmurs simulate each other very closely. 

Acute Pericarditis with Exudation. — Symptoms. — The subjective 
symptoms of acute pericarditis with exudation in infancy are very in- 
definite, and throughout childhood this latency of the early symptoms is 
so marked and occurs so frequently that it may be said to be character- 
istic of the symptomatology of pericarditis in early life. It is so difficult to 
locate pain when it occurs in the infant, and a tumultuous action of the 
heart with general circulatory disturbance is so commonly the result of a 
diseased condition outside of this central organ, that it is impossible to 
formulate a practical general symptomatology for the onset of the disease. 
When, however, the disease has progressed, dyspnoea and orthopncea 
become marked. Large exudations appear to affect the functional activity 
of the heart more rapidly in children than in adults, and to occasion earlier 
the signs of disturbance of the circulation, such as cyanosis and coldness 
of the nose and extremities. Diminution in the amount of the urine, 
with a corresponding increase in the urine as the exudation decreases, has 
been noticed in children. 

Physical Signs. — The usual physical signs supposed to be character- 
istic of pericarditis are often very misleading, and when a pericardial 
friction-sound is absent the diagnosis of pericarditis in a young child may 
present great difficulties. 

Inspection. — Owing to the flexible thorax of the child, there is a greater 
opportunity for the neighboring parts to yield before the pressure of the 
fluid, and we are more likely to have bulging of the intercostal spaces, 
and on inspection a visible alteration of the cardiac area, than in adults. 

It has been held by certain authorities that the heart's apex is found in 
effusions to be tilted upward and inward towards the sternal end of the 
fourth left interspace, — that is, floated by the effusion. Direct proof of 
this is wanting, and I believe, from my investigations on this subject, 



756 PEDIATRICS. 

that it is an erroneous view. It would seemingly be impossible for the 
heart to be floated unless the specific gravity of the fluid was greater 
than 1050, as I have shown by experiment. It is highly improbable 
that the specific gravity would be greater than 1050 in an ordinary peri- 
cardial exudation, for the specific gravity of a purely purulent fluid is 
only about 1032. Ludwig and Bowditch have, moreover, observed that 
the impulse of the heart as seen normally in the fifth left interspace need 
not be caused by the heart's apex, but may be caused by a portion of the 
heart above the apex striking against the thoracic wall. We should also 
consider that the impulse of the heart in children is often chiefly in the 
fourth interspace. It seems plausible to account for this pulsation by the 
tumultuous action of that portion of the right ventricle which, as shown 
by Rotch, is not covered by the moderate amount of fluid in the fourth 
left interspace when an exudation is present. 

In the third case on page 761 it is recorded that the impulse was found 
throughout the whole cardiac area, but that it was still pronounced in the 
fifth left interspace. If in this case there had been a larger exudation, the 
apex and the lower segment of the right ventricle being surrounded by a 
mass of fluid, the impulse would have been lost in the fifth interspace, 
while in the fourth interspace, in which the ventricle may be covered by 
only a thin layer of overlying fluid, the impulse would have continued 
to be both seen and felt, thus simulating an apex-beat. I believe this is 
the explanation of what has been called misplaced apex-beats and floating 
of the heart in pericardial effusions. 

Palpation. — When the amount of fluid is considerable the palpable 
impulse is much diminished, and its intensity corresponds to the place in 
which the visible impulse is most distinct. 

Auscultation. — The friction-sound is often absent, but if present in the 
beginning disappears as the fluid increases, and may reappear when ab- 
sorption takes place. The heart-sounds are diminished in intensity, but 
may be heard most distinctly in the fourth interspace at the point of the 
visible impulse. On account of the small size of the child's thorax, the 
heart and pericardium are much nearer to the anterior surface of the 
thoracic cavity than in adults. This occurs both normally and in diseased 
conditions, especially when there is flattening, and thus levelling, of the 
chest. Under these latter conditions the heart and pericardium are 
brought in such close contact with the thoracic wall that on palpation the 
heart's impulse can be felt, and on auscultation the heart-sounds can be 
heard in a much more advanced stage of a pericardial effusion than would 
be possible in the adult with a proportionately large amount of fluid, 

According to E warts, a pericardial exudation may give rise to a patch 
of tubular breathing about two inches below and slightly to the left of the 
left scapula, but the same sign may occur in pleuritic exudation. 

Percussion. — Percussion is the most important physical sign, when the 
initial friction-sound has escaped detection, both for determining whether 



DISEASES OF THE PERICARDIUM. 757 

an exudation is present and as a guide to the prognosis and treatment. 
In exudations of exactly the same amount the area of dulness may differ, 
owing to the difference in the elasticity of the lungs and to the presence 
or absence of adhesions. The greater the elasticity of the lungs and the 
fewer the adhesions the more regular will be the outline of superficial 
dulness. This superficial dulness is determined by the retraction of the 
borders of the lungs, which withdraw from the chest walls as the fluid 
gradually distends the pericardium. The deep dulness is due to the dis- 
tended pericardium, and this to a greater or less degree compresses the 
lungs, which may he held in position by adhesions. The infant, being 
less likely to have had previous lesions of the lung and pericardium, gives 
us the best opportunity for studying the outlines of a pericardial effusion, 
and the area of superficial dulness is the most valuable physical sign of 
effusion in infants and in young children. 

The experiments (Keating' s Cyclopaedia of Diseases of Children) on 
which I have based my conclusions regarding the area of dulness in peri- 
cardial effusions were made on sixteen infants, in none of whom did ad- 
hesions exist. In all of these presumably typical cases absolute dulness 
w T as found to the right of the sternum. An instance of how the area of 
dulness varies in cases complicated with adhesions was given by a case 
in which, although the pericardium was much distended with fluid, it 
failed to show dulness to the right of the sternum, and the autopsy re- 
vealed adhesions binding the lung tightly to the right edge of the sternum. 
The effusion was behind the lung, which permitted resonance to be ob- 
tained over an area where, in an uncomplicated case with the same 
amount of effusion, there would have been dulness. 

In addition to the difficulties of making a differential diagnosis arising 
from interference with the contractility of the lungs, such complications as 
pneumonia of the right lung, especially its middle lobe, pleuritic effusion 
on the right side, an enlarged liver, and an enlarged heart must be con- 
sidered. When this pneumonia, or pleurisy, or hepatic enlargement is 
present, an effusion into the pericardium cannot be diagnosticated by 
means of percussion, but the associated disease can usually be readily 
determined by its especial symptoms. The differential diagnosis, on the 
contrary, from an enlarged heart, especially a dilated heart in which 
the murmurs may be absent, can often be made only by means of per- 
cussion. 

The superficial dulness of the heart is determined not by the shape of 
the heart itself, but by the marginal lines of the lungs, varying according 
to their expansion or retraction. Moreover, the pericardium itself, 
whether distended with fluid or not, does not by its own shape, as has 
been delineated so often in the plates illustrating pericardial effusions, aid 
us materially in determining the shape of the area of superficial dulness 
in a pericardial effusion. This area is marked by the retracting or rather 
displaced borders of the lungs. 



758 PEDIATRICS. 

When from 70 to 88 c.c. (2J to 2f ounces) of fluid are introduced 
into the pericardium of an adult, there is a slight increase in the vertical 
as well as in the transverse area of dulness. The curved line which 
bounds the area of dulness starts at the sixth rib, to the right of the 
sternum, passes upward to the junction of the fourth cartilage with the 
sternum, impinges on the lower part of the third left interspace, and then 
descends just outside of the mammillary line' to the sixth rib, to pass in- 
ward until it meets the dulness of the left lobe of the liver. This line 
forms an irregular semicircle, with a shorter radius to the right of the 
sternum and a longer one to the left. 

A small section of the dull area, corresponding to the junction of the 
fourth and fifth ribs with the left side of the sternum, is formed by the 
heart itself, which is free from effusion at this point, while the rest of the 
dulness is produced by the effusion. The layer of fluid is very thin all 
over the upper portion of the effusion in the region of the fourth rib and 
fourth interspace, while the mass of the effusion is in the lower part of 
the sac on each side of the sternum in the fifth interspaces, the larger 
part of the mass being on the left side. 

The same conclusions as to the area of dulness were obtained with a 
proportionately small amount of fluid in an infant about two weeks old ; 
and of sixteen injections of fluid into the pericardial sac of infants of 
various ages the areas of dulness were identical in all, and in all the 
lungs were normal and there were no pulmonary or other adhesions. 

When the amount of fluid in the pericardial sac is large, the transverse 
area of dulness produced by the much distended pericardium is increased 
so that it extends farther to the right of the sternum in the fourth and 
fifth interspaces, and then, rising to the third interspace, it occupies a 
small area on either side of the sternum under the third, second, and 
first ribs and the second and first interspaces, the upper lobes of the lungs 
having retracted from beneath the sternum. As the effusion increases 
the lungs retract still more, and the upper curved lines of the effusion on 
either side of the sternum present areas with still greater diameters. 

According to Ewarts, a pericardial exudation may at times give rise 
to a patch of dulness in the back represented by a sharply defined square 
area bounded by the ninth or tenth rib above and the twelfth rib below, 
on the right by the spine, and on the left by a vertical line from the angle 
of the scapula. Over this area the respiratory sounds are absent and the 
voice-sounds feeble. I have observed these same signs in an unreported 
case in which the dulness disappeared as the pericardial effusion was 
absorbed. This dorsal patch of dulness is present normally in children 
up. to the age of four years, due to the large size of the liver at this age. 

Ewarts has also given as a point in the differential diagnosis between 
pericardial exudation and cardiac dilatation, that in a dilated heart the 
curve of the right border of dulness is directed downward and inward 
towards the ensiform cartilage, while in a pericardial exudation the curve 



DISEASES OF THE PERICARDIUM. 759 

is directed either downward or downward and outward. This distinction 
is more easily made in moderate than in very large exudations, as shown 
in Fig. 158, page 760. 

Diagnosis. — From what has been said regarding the latency of the 
general symptoms of pericarditis in childhood and the difficulty of inter- 
preting the local symptoms, it will be readily understood how important 
it is to recognize any especial symptoms which may characterize the dis- 
ease. Instances have been reported in which a distended pericardium 
was mistaken by experienced diagnosticians for an exudation into the 
left pleura. The diagnosis as to the character of the effusion, whether 
serous or purulent, can only be made by aspiration. In infants the fluid 
is almost uniformly pus ; this is also the case in the majority of older 
children, except in rheumatic infections. The condition which most 
closely simulates a pericardial exudation, both in its general symptoms 
and in its physical signs, is a dilated heart. 

The most distinctive of all the physical signs of pericarditis is the 
friction-sound, when it is present, but it must be carefully differentiated 
from the sound produced by a dry pleurisy in the cardiac area. When, 
however, an exudation has taken place, the friction-sound may not be 
heard. This absence of a friction-sound is especially frequent in young 
children. The heart's impulse may be clearly perceptible, even when a 
considerable exudation is present, owing to the thin layer of fluid which 
covers the heart in the area between the left nipple and the sternum. 
We are therefore forced by the similarity which at times exists between 
the general symptoms, in the inspection, palpation, and auscultation of a 
dilated heart and of a pericardial exudation, to depend upon percussion in 
making a differential diagnosis. 

According to careful observations which have been made by com- 
petent observers on the area of dulness which can be produced by an 
enlargement either of the ventricles or auricles of the heart, whether by 
hypertrophy or by dilatation, the relative dulness may extend to the right 
of the sternum from the second to the sixth rib, and in adults possibly to 
the distance of 3 or 4 cm. (1-J- or 1J inches) on a level with the fourth 
rib, but it is rare to find this dulness invading the fifth right interspace 
more than 2 or 3 cm. (J or 1| inches). It is still more rare for the abso- 
lute dulness to be found in the fifth interspace at all, and even in the 
fourth interspace for more than 1.5 or 2 cm. (J or f- inch). 

We may conclude, therefore, that the dulness which occurs in a peri- 
cardial effusion may correspond to that of an enlarged heart, but that 
the dulness of the effusion is also found in an additional area correspond- 
ing to a part of the fifth rib and fifth interspace. Absolute dulness, 
therefore, in the fifth right interspace 3 or 4 cm. (1-|- or 1J inches) from 
the right sternal line in cases of pericarditis uncomplicated by pleural or 
pericardial adhesions is a sign of much value in the differential diagnosis 
from an enlarged heart. I have found in my experiments on the adult 



760 PEDIATRICS. 

pericardium that the superficial dulness could be detected in the fifth right 
interspace when from 70 to 80 c.c. of fluid had entered the pericardium. 
In order to illustrate the difference between the area of dulness pro- 
duced by an enlarged heart and that produced by a pericardial effusion, I 
have indicated in Fig. 158, a boy, eleven and a half years old, the boun- 




Areas of absolute dulness in enlarged heart, and in distended pericardium. 5, fifth right interspace ; 

H, heart. 

daries of the area of absolute dulness in an enlarged heart, in a small 
pericardial effusion, and in a large pericardial effusion. 

The top of the sternum, the boundaries of the enlarged heart, the 
ensiform cartilage, and the lower border of the ribs are marked by plain 
black lines, the boundaries of the small effusion by a broken line, and 
the area of the large effusion by a larger broken line. The figure 5 
marks the fifth right interspace ; the letter H marks that portion of the 
heart which has been left uncovered by the small effusion. The small 
black circle represents the normal position of the apex of the heart, the 
larger circle the apex of the enlarged heart. It will be noticed how the 
enlarged heart extends beyond the right edge of the sternum at about the 
fourth rib and fourth interspace, and then returns beneath the lower part 
of the sternum within or a very little outside of the right sternal line. 



DISEASES OF THE PERICARDIUM. 



761 



The outline of the small effusion, as well as that of the large effusion, 
extends to the right of the sternum as low as the sixth rib. 

The following cases, taken from a number which have come under 
my care, illustrate the difficulty of making a differential diagnosis between 
cardiac and pericardial disease when, as at times happens, we fail to find 
a friction-sound or murmurs : 

TABLE 71. 

Differential Diagnosis betioeen a Dilated Heart and a Pericardial Effusion. 



Case I. 
Endocarditis ; Dilated Heart. 



Girl, eleven years. 

Attack followed acute artic- 
ular rheumatism. 

Orthopnoea; precordial pain. 

Heart's impulse feeble, but 
perceptible a little to left 
and below left nipple, fifth 
interspace. 



Vertical absolute dulness not 
increased. 

Absolute dulness under the 
sternum and to left of 
sternum ; identical with 
Cases II. and III. 

Absolute dulness did not ex- 
tend to right of sternum. 



Systolic murmur at apex. 



Recovery. 



Case II. 
Pericarditis ; Effusion. 



Boy, six years. 

Attack followed acute artic- 
ular rheumatism. 

Orthopnoea ; precordial pain. 

Heart's impulse feeble, but 
perceptible a little to left 
and below left nipple, fifth 
interspace. 



Yertical absolute dulness not 
increased. 

Absolute dulness under the 
sternum and to left of 
sternum ; identical with 
Cases I. and III. 

Absolute dulness in fifth 
right interspace two or 
three centimetres from 
edge of sternum. 

Pericardial friction-rub at 



Recovery. 



Case III. 

Endocarditis ; Enlarged Heart ; 

Pericardial Effusion. 



Girl, eight years. August 3. 

Attack followed acute articular 
rheumatism. 

Orthopnoea ; precordial pain. 

Heart's impulse feeble, but per- 
ceptible all over cardiac area, 
with apex-beat a little below 
and to left of left nipple, fifth 
interspace. 

Vertical absolute dulness not 
increased. 

Absolute dulness under the ster- 
num and to left of sternum ; 
identical with Cases I. and 
II. 

Absolute dulness in fifth right 
interspace three or four cen- 
timetres from edge of ster- 
num. 

Soft systolic murmur at apex, 
transmitted to axilla. Peri- 
cardial friction-rub at base. 

August 6 : Less dulness in fifth 
right interspace ; apex mur- 
mur much louder and harsh. 

August 11 : Dulness only to 
right edge of sternum. 

August 18 : Dulness only to 
middle of sternum ; friction- 
rub ceased. 

December 1 : Physical examina- 
tion the same as on August 
18, showing enlarged heart 
and mitral svstolic murmur. 



762 PEDIATRICS. 

The symptomatology, both general and local, of these cases was, with 
the exception of the friction-sounds, murmurs, and percussion, identical ; 
when fluid was present dulness was found in the fifth right interspace, 
and when it was absent dulness was not found. 

Prognosis. — The prognosis of acute pericarditis depends largely upon 
its cause. In early infancy it is a very serious condition, and generally 
ends fatally. In later childhood its course and results are much the same 
as in adults, and the disease has a tendency to recovery, especially if the 
exudation is sero-fibrinous and of rheumatic origin. The purulent, septic, 
and tubercular forms are of grave import in all cases. 

Treatment. — The treatment of pericarditis in infancy and in early 
childhood does not differ materially from that in later life, and depends 
upon the various causes referred to in the etiology of the disease. The 
tendency to heart-failure, however, which is so pronounced in the child, 
should be guarded against. Early in the disease absolute physical and 
mental rest should be enforced. In the acute stage, before an effusion of 
any extent has formed, cold can be applied to the cardiac region by means 
of coils of tubing containing ice-water or by an ice-bag. An important part 
of the treatment is the judicious administration of digitalis to aid the heart 
in the crippled condition in which it is usually left after the early days of 
the disease. Stimulants should be freely used when there is any indication 
of failing compensation. 

The most important part of the treatment when an effusion of any 
extent has occurred is paracentesis of the pericardium, which should un- 
hesitatingly be performed, no matter what the cause of the disease may be, 
when life is in danger from undue distention of the pericardial sac. A 
small aspirating trochar should be used. Opinions differ widely as to the 
best point of puncture. Inasmuch as the heart, when an effusion is pres- 
ent, remains in its usual position, and does not, even when much enlarged, 
impinge on the fifth right interspace, and as the effusion, even when in 
so small an amount as 100 c.c, is found at that point, I consider it more 
rational to choose the fifth right interspace, 4 cm. (1 j inches) outside the 
right border of the sternum, as the point for tapping, thus avoiding all 
danger of injuring the heart. At this point the right internal mammary 
artery will not be injured. I have tapped the pericardium in the fifth right 
interspace a number of times on the cadaver, and have removed the fluid 
as easily as in the fifth left interspace. The pericardium has been tapped 
during life in the fifth right interspace by Ebstein, of Gottingen, Wilson, 
of Nashville, Lovejoy, of Lynn, and a number of others. Another place 
to aspirate, recommended by Osier, is the left fourth interspace, either 
close to the sternal margin or 2.5 cm. (one inch) from it, in order to 
avoid wounding the internal mammary artery. The left fifth interspace, 
3.75 cm. (1 J inches) from the sternal border, may also be taken for the 
point of puncture, and if the aspirated fluid is found to be purulent, the 
case should be treated surgically by free incision. 



DISEASES OF THE PERICARDIUM. 768 

As an illustration of how important it is to tap the pericardium when 
it is much distended with fluid and when symptoms of failing heart have 
arisen, the following case may be cited : 

A boy, six years old, entered the hospital with the history of having had oedema 
of the face, hands, feet, and ankles for four weeks. There was no history of rheu- 
matism, and the case was apparently one of acute primary endocarditis with mitral 
insufficiency. The cardiac area of dulness was increased, and extended from the 
middle of the sternum to 1.5 cm. (J inch) beyond the left mammillary line, where 
the impulse of the heart could be felt." The child was kept quiet in bed, and after a 
few days the oedema lessened and he was very comfortable. While still under treat- 
ment, two weeks later, the temperature, which had been normal, rose to 39.1° C. 
(102.5° F.), the pulse was rapid and somewhat irregular, and the respirations were 
increased. A few days later a pericardial friction-sound was heard over the upper 
part of the sternum, and the temperature fell to 37.7° C ; (100° F.). There was no 
change in the area of cardiac dulness, and no evidence of a pericardial effusion. 

On the following day the cardiac sounds were found to be rather muffled and 
the child did not seem so well, and was unable to lie on his left side. Two days later 
the area of precordial dulness extended farther to the right, and a little beyond the 
right sternal line in the fifth right interspace. The attendants were directed to watch 
the child closely, and warning was given that the necessity for paracentesis of the 
pericardium might at any time arise. Early the following morning the child began to 
have marked dyspnoea and became very cyanotic. The house-officer found that the 
precordial dulness had extended 2.7 cm. (1 inch) beyond the right edge of the sternum 
in the fifth interspace, and he therefore got the instruments ready for performing para- 
centesis. Suddenly the child's pulse became very weak and intermittent, the cyanosis 
increased very much, the dyspnoea became very marked, and, although stimulants were 
quickly given, the child suddenly gasped and fell back on its pillow dead. This oc- 
curred within three-quarters of an hour from the time when the first serious symptoms 
arose. The house-officer immediately introduced the aspirating needle in the fifth 
right interspace and withdrew some fluid from the pericardium. The child, however, 
did not revive. 

The following case illustrates a pericarditis sicca with adhesions : 

The child was six and one-half years old. She had never had rheumatism, but 
had had an attack of measles when she was two years old, pertussis when she was 
two and one-half years old, and parotitis when she was three and one-half years old. 
Four months previous to her second entrance to the hospital she had an attack of 
chorea, of so mild a grade, however, that she was able to go to school until she entered 
the hospital. At that time, although she did not show any especial cardiac symptoms, 
an examination of the heart showed a latent and insidious endocarditis, represented 
by an increase of the superficial area of cardiac dulness to the left of the mammillary 
line, but not extending under the sternum, with a systolic murmur transmitted to the 
axilla, but not heard in the back. Compensation soon became complete, and she re- 
covered from the chorea. 

Two days before her second entrance to the hospital she was attacked with dyspnoea, 
rapid respirations, and cardiac pain. 

On examination the child seemed very sick, and showed a considerable increase 
to the left in the area of cardiac dulness, and at the junction of the third rib with the 
sternum a marked precordial friction-sound, but with no enlargement to the right. 

The precordial pain, discomfort, and heightened temperature lasted for a few days, 
and were in the beginning accompanied by orthopncea and by an increase in the loud- 



764 PEDIATRICS. 

ness of the friction-sound. There was at no time, however, any evidence of an effusion 
in the pericardium, and one week afterwards the friction-sound became less distinct, 
disappearing three days later. The child, however, grew much weaker, and, although 
she was treated by complete rest in bed and with digitalis, strophanthus, and stimu- 
lants, the precordial pain returned, and she gradually failed and died. The pulse 
varied from 130 to 150, and the respirations from 50 to 80. The temperature was only 
moderately elevated throughout the attack, ranging between 37.7° to 38.8° C. (100° to 
102° F.) most of the time. 

The autopsy showed the pericardial sac to be obliterated everywhere by firm fibrin- 
ous adhesions. The heart was enlarged. Along the edges of the mitral valve were 
numerous small grayish-white vegetations. These were also present on the aortic 
valves and on the portion surrounding the tricuspid valve. The lungs were denser 
than normal, and were deeply injected and (Edematous. The pleura on the inner 
surface of the right lower lobe was adherent to the pericardium by fibrinous adhesions. 
The surface of the liver was covered with a thin layer of fibrin. The liver and kidneys 
were a little denser than normal, but were not noticeably congested. 

The anatomical diagnosis was chronic adhesive pericarditis, acute vegetative endo- 
carditis, acute fibrinous pleurisy, acute fibrinous perihepatitis, and hypertrophy and 
dilatation of the heart. 

The next case was one of marked pericardial effusion, which was 
absorbed : 

A little girl, eight years old, during the first two years of her life had scarlet fever r 
varicella, and pertussis. When she was two years old she had an attack of measles, 
and when she was seven years old an attack of chorea. During the last year she was 
fairly well until two weeks before entrance, when it was noticed that her feet began to- 
swell, she complained of pain in her limbs, and occasionally of headache, she lost in 
weight, and had had orthopnoea with frequent paroxysms of dyspnoea. She also at 
times complained of pain in her left chest. Her extremities were apt to be cold. She 
had a short, dry cough. A physical examination showed the impulse of the heart to be- 
feeble, but it could be felt all over the cardiac area. There was an area of precordial 
dulness extending to the right of the sternum almost to the right mammillary line, as low 
as and involving the fifth interspace and as high as the third interspace and to the left 
a little beyond the left mammillary line to the sixth rib. There was a systolic murmur 
at the apex, which was transmitted to the axilla. The pulmonic second sound was- 
accentuated. There was a precordial friction-sound heard at the upper part of the 
sternum. The history of the case and the area of precordial dulness showed that it 
was a case of pericarditis with effusion. There may also have been some endocarditis, 
evidence of which is given by the mitral systolic murmur. The child was treated by 
rest in bed and by digitalis. 

Two weeks later the friction-sound disappeared, and the precordial dulness grew 
less, so that it extended only to the middle of the sternum. In the next two week& 
the dulness beneath the sternum disappeared, and the mitral murmur lessened, but 
could still be heard 2 cm. (f inch) outside of the mammillary line. 

CHRONIC ADHESIVE PERICARDITIS. 

Chronic adhesive pericarditis may occur in infancy and childhood. It 
is the result of acute inflammatory processes, in the course of which the 
parietal and visceral layers of the pericardium become adherent by the 
fibrinous exudation, which later becomes organized fibrous tissue. These 
adhesions may be partia or complete, involving the obliteration of the en- 



DISEASES OF THE PERICARDIUM. 765 

tire pericardial cavity. Well-marked adhesions of the pericardial surfaces 
have been observed in an infant who died thirty-six hours after birth. 

If the adhesions are limited to the visceral and parietal layers of the 
pericardium, there may be no resulting cardiac disturbance, and in many 
cases there is neither hypertrophy nor dilatation. 

If, however, an obliterated pericardium is associated with inflamma- 
tory adhesions between the outer layers of the pericardium and the 
pleura and chest walls, the hypertrophy of the heart may become extreme 
and eventually result in dilatation or sudden death. 

The white, opaque thickenings of the inner pericardial surface so 
frequently found in adults are rare in children, but have been found at 
all ages, and when there is a deformity of the chest, as in certain cases 
of rhachitis, they have been especially noticed. The younger the subject 
the less likely are there to be adhesions between the pericardium and the 
pleura, an important fact, to be taken into consideration when making a 
diagnosis of pericardial effusion in infancy. The frequency of pericar- 
dial adhesions is shown in Lee's series of one hundred and fifty autopsies 
in cardiac disease of rheumatic origin, in which one hundred and thirteen 
cases had pericardial adhesions, and of these, seventy-seven had complete 
adhesion. An important result of pericarditis is the injury done to the 
myocardium through the intimate connection between the visceral layer 
of the pericardium and the heart-muscle. Lee in thirty-four of his cases 
found changes in the myocardium after pericarditis. 

In the fibrinous pericarditis of rheumatic origin the process is likely 
to be of a very mild grade, with but a slight increase in the connective 
tissue between the membranes, and consequently with but little thicken- 
ing. The most extreme cases of thickening of the pericardial membrane 
is met with in the chronic tubercular form. In these cases there is always 
a primary tuberculosis of the mediastinal or bronchial lymph-nodes. The 
tubercular process invades the pericardium by extension from these foci. 
This is not an uncommon process in children. Of sixty-five cases col- 
lected by Brackman, nineteen occurred in children. 

After the absorption of an extensive purulent or sero-purulent exuda- 
tion, the resulting thickening of the pericardium may be increased by the 
deposition of lime-salts within the membranes leading to calcification. 
Such areas of calcification are most frequently found over the auricles or 
at the base of the heart. According to Osier, the heart may be com- 
pletely invested by a calcareous membrane which in places may be from 
1 to 1.5 centimetres ( T 6 g- to T 9 -g- inch) in thickness. 

Symptoms. — The symptoms of adhesive pericarditis are not distinctive. 
They are generally dependent upon the condition of hypertrophy and 
dilatation which is present and upon the degree of compensation. 

At times the symptoms are suggestive of cirrhosis of the liver, — that is, 
enlargement of the liver and ascites. When these occur without obvious 
cause in a young person, adhesive pericarditis should be suspected. 



766 PEDIATRICS. 

When severe cardiac symptoms are present in young children and no 
valvular murmurs are heard, we should think of degeneration of the 
heart-muscle itself or of pericardial adhesions. When, again, the super- 
ficial area of dulness remains unchanged and there are well-marked sys- 
tolic retractions, the presence of pericardial adhesions is highly probable. 

Diagnosis. — The chief diagnostic points of adherent pericardium asso- 
ciated with chronic mediastinitis, are bulging of the chest, systolic retrac- 
tion at the cardiac apex, or in Traube's space, and systolic retraction in 
the line of the attachment of the diaphragm (Broadbent's sign). Associ- 
ated with this retraction may often be seen a diastolic collapse of the 
cervical veins, the so-called Friedrich's sign. Systolic retraction, however, 
may occur in pronounced hypertrophy without adhesions. 

An extreme dilatation of the heart with an adherent pericardium will 
give rise to signs which closely resemble pericarditis with exudation. The 
distinction between these two conditions can only be made by the very 
closest observation of the physical signs of pericardial exudation as de- 
scribed on page 755. The majority of the cases of adhesive pericarditis 
are not recognized during life, and are only discovered at the autopsy. 

Treatment. — The treatment is symptomatic, the endeavor being made 
to maintain the compensation of the heart. When ascites is present, 
withdrawal by paracentesis may aid in the palliative treatment. 



DIVISION XII. 

DISEASES OF THE OESOPHAGUS, STOMACH, AND 

INTESTINE. 



INTRODUCTION. 



Before speaking in detail of the diseases of the stomach and intestine, 
a few general remarks are necessary to explain how limited is our knowl- 
edge of these diseases. Those diseases, however, which affect the oesoph- 
agus can easily be classified on a pathological basis, and are so few in 
number that they can be included in these general remarks. 

CESOPHAGUS. — The diseases of the oesophagus are rare in infancy 
and early childhood. There may be congenital malformations, such as 
absence or obliteration, narrowing or dilatation, and fistulous communica- 
tion with various parts, such as the trachea, or that congenital condition 
called "branchial fistula," described on page 296. The swallowing of hot 
or corrosive liquids may cause obstruction, which is occasioned by a cica- 
tricial stricture. (Esophageal stricture may also occur as a result of con- 
genital syphilis. Pressure outside of the oesophagus may cause obstruction. 
These strictures, especially those of cicatricial origin, are accompanied by 
a great deal of muscular spasm, which at times is constant, and again re- 
laxes. Thus, the child will swallow with comparative freedom at inter- 
vals, while at other times the obstruction appears to be complete. In 
addition to the inability to swallow, and the consequent regurgitation of 
the food, the secretion of saliva and mucus is often very profuse, and 
causes symptoms of distress and choking. 

The diagnosis and treatment of these cases are effected chiefly by 
means of bougies ; but, as much harm may come from these instruments, 
and as especial surgical knowledge is required to use them and to decide 
whether cesophagotomy should be performed, I shall not dwell on this 
class of cases. 

An inflammatory condition of the oesophagus is said to occur in young 
infants, and is spoken of as oesophagitis. It is rare. The symptoms, as 
described by Billard, are unwillingness to nurse, crying, immediate regur- 
gitation after beginning to suck, and often some tenderness about the neck 
on pressure. The prognosis is bad. The treatment of the active stage 

767 



768 PEDIATRICS. 

of the more severe forms, such as the corrosive, is by the administration 
of emollients and ice. Morphia may be required for the pain. 

It is quite common for children to swallow various foreign bodies, such 
as buttons and pins. These bodies may either be caught in the back of 

Fig. 159. 



x : 



p 

Congenital dilatation of oesophagus, female, 10 weeks old {% natural size). 

the throat or lodged in the oesophagus, instead of passing through to the 
stomach. A careful examination of the throat with the finger should first 
be made, and if the foreign body is not detected in the throat the oesoph- 
agus should be explored carefully with a bougie, and the foreign body is 
then usually pushed through into the stomach, unless it is thought wiser 
to remove it with the bristle probang. The diet for the following twenty- 
four to forty-eight hours, or until the body has been passed through the 
intestine, should be such as will give sufficient consistency to the faeces 
to protect the intestine from injury while the body is being passed over 
its surface. Various preparations of the cereals are useful for this pur- 



DISEASES OF THE (ESOPHAGUS. 769 

pose. If necessary, a dose of oil can be given, but, as a rule, active 
treatment is contra-indicated. 

The oesophagus and stomach of an infant ten weeks old, with con- 
genital dilatation of the oesophagus is shown in Fig. 159. 

The infant was healthy at birth, and its mother had a plentiful supply of breast-milk. 
During the first two or three weeks of its life nothing abnormal was noticed about it, ex- 
cept that it vomited occasionally. When it was four weeks old it began to regurgitate, 
vomited the milk frequently, and lost in weight. The faecal discharges showed that the 
milk which reached the stomach and intestine was fairly digested, but the discharges were 
infrequent and small in number. It was weaned when it was nine weeks old, and small 
amounts of milk, carefully modified in various ways, were given to it. No improvement 
in the symptoms followed this treatment, and although at times a small quantity of milk 
would be retained, yet, as a rule, after a few minutes the milk was regurgitated. The 
infant had no other symptoms, but rapidly lost in weight, and finally died of exhaustion. 
The post-mortem examination was made by Dr. Whitney, and the only pathological 
conditions found were in the oesophagus. . The last two inches of the oesophagus were 
dilated into a more or less cylindrical swelling, with marked thinning of the walls and 
atrophy of the mucous coat. A dilatation had been formed in which evidence of a small 
area about to perforate into the mediastinum was found. The entire stomach, as well as 
its cardiac and pyloric orifices, was markedly contracted, apparently from lack of use. 

STOMACH AND INTESTINE.— Our knowledge of the diseases of 
the stomach and intestine is exceedingly limited, and is especially so when 
infants and young children are concerned. The classification of these dis- 
eases on a pathological basis has been proved to be inadequate, and in like 
manner a classification on the basis of symptoms is insufficient. Bacterio- 
logical investigations, however, have advanced our knowledge to such an 
extent that we may hope in the future to be able to classify these diseases 
on an etiological basis. The terms dyspepsia, dysentery, diphtheritic, 
croupous, and others have become almost unmeaning, and should be re- 
placed by terms more closely connected with the etiology of the disease. 

In 1894 the American Pediatric Society requested Dr. Holt and 
myself to prepare a nomenclature which would correspond more nearly to 
our present knowledge of this exceedingly difficult subject. I wish es- 
pecially to emphasize the value of Holt's work, which has aided me so 
much in my own studies on this subject. The classification finally adopted 
by the Society was one which especially relates to infants and young 
children, and it is this early period of life that is about to be described. 
The diseases of the gastro-enteric tract as they occur in older children 
resemble so closely those of adults that they do not occupy a prominent 
place in the clinical medicine of children, especially as the pathology and 
symptoms of this later period of life differ very materially from those of 
the earlier periods. These differences are still more strongly marked 
from the fact that children succumb much more readily to the early stages 
of a disease than do adults, and may die before the later and more 
characteristic lesions and symptoms of the disease have developed. There 
are certain known facts resulting from the anatomical and physiological 

49 



770 PEDIATRICS. 

peculiarities existing in infancy which play a significant part in all these 
diseases. It is well, therefore, first to explain the general principles which 
influence the symptoms and prognosis of these diseases before attempting 
to describe each disease separately. In many cases we can arrive at only 
approximate conclusions as to the actual lesion which exists and the prog- 
nosis which should be given. A practical clinical diagnosis should be 
made according to the region in which the stress of the lesion exists, rather 
than to all the pathological lesions which are present. 

General Etiology. — In the present state of our knowledge it is not 
practicable to discuss in detail the various supposed causes of gastro- 
enteric disturbances. We can suppose that these disturbances may be 
due to nervous conditions which may act alone or may render the tissue 
vulnerable to bacteria. Some of these diseases are caused by specific 
organisms, while others are due to a number of organisms. These bac- 
teria act either of themselves or through their products. 

In a general way, these diseases can be classified as functional and 
organic. The organic class may be divided into inflammatory and non- 
inflammatory diseases, although the boundary-line between these two con- 
ditions is at times very doubtful. A prominent and important peculiarity 
of these diseases as they occur in infancy is, as would naturally be expected 
at this early period of development, a variety of symptoms which are pro- 
duced by reflex causes. By the term reflex we mean peripheral irritation 
with a resulting action. By functional we mean a disturbance of the function 
of the organ without a known lesion. By organic we mean a known lesion. 

In addition to these cases are others which, as yet imperfectly under- 
stood, seem to be produced by certain morbid products eliminated from 
the blood by the gastro-enteric tract, as, for example, urea. This etiologi- 
cal factor can be spoken of under the term eliminative. 

General Pathology. — The general pathological anatomy of the gastro- 
enteric tract of infancy and early childhood is essentially that of the ileum 
and colon. In those cases in which the more severe lesions are present 
the stress of the lesion is usually in the lower ileum and the colon, and 
very frequently in the colon only. For this reason the terms ileo-colitis 
and colitis seem more descriptive than ileo-enteritis and enteritis. The 
pseudo-membrane in ileo-colitis is often extensive, but sloughing and per- 
foration are exceedingly rare in young children. It is at present believed 
that not all ulcers of the gastro-enteric tract are necessarily inflammatory. 
The great number of lymph-nodules and the abundance of the lymphatic 
plexuses are the principal anatomical conditions which influence the 
pathology of the enteric tract in early life. 

General Bacteriology. — The knowledge of the different bacteria which 
occur in the gastro-enteric tract, and of the connection which they have 
with the different diseases, is at present, with few exceptions, uncertain 
and unreliable. The proteus group has, however, been most commonly 
found in cholera infantum, while in the cases of fermental diarrhoea the 



DISEASES OF THE STOMACH AND INTESTINE. 771 

ordinary saprophytic bacteria become prominent, especially the hay bacil- 
lus. These bacteria usually enter the system through milk, but may enter 
through other sources. There is little doubt that the bacteria may find 
their way, by means of the stomach, to the intestine, and that the acid 
secretion of the stomach which they meet in their way through it is not 
sufficient to prevent their arriving alive in the intestine. We know that 
these bacteria play such an important role in their etiological relations to 
the various diseases that full weight must be given to their presence when 
we are treating the disease. It would seem that the bacteria which are 
commonly found in the intestine when it is in a normal condition do not 
cause any abnormal conditions ; but when the intestine has become irri- 
tated, from mechanical or thermic causes, the bacteria are able to pene- 
trate its mucous membrane, become noxious, and produce abnormal 
symptoms, often of a serious nature. 

General Symptomatology. — Vomiting as a symptom is often very mis- 
leading in early life, so far as the differential diagnosis between the stom- 
ach and the intestine is concerned, as it frequently occurs from disturbance 
in any part of the gastro-enteric tract, and should not be considered as 
indicative of any one disease. Serious symptoms during life are often 
proved at the autopsy to have been produced by no pathological lesion, 
while grave lesions may be found at the autopsy where the intestinal 
symptoms during life were very mild. 

Marked diarrhoea may exist during life and no lesions be present at 
the autopsy. Serious lesions may exist, and yet no blood appear in the 
dejections. Blood may appear in the dejections, and yet no serious 
lesion exist, the hemorrhage being only temporary, and comparable to 
epistaxis. 

General Diagnosis. — The observation of the temperature is very im- 
portant for the diagnosis of these diseases. As a rule, an elevated tem- 
perature of short duration points towards functional and toxic disturb- 
ances, while an elevated temperature long continued points towards 
inflammatory lesions. The chemical examination of the gastric contents 
in infants has so far proved to be unsatisfactory both for diagnosis and 
treatment. 

Intestinal discharges are often very misleading in making a diagnosis. 

Having considered and accepted these general principles relating to 
diseases of the gastro-enteric tract in infancy, the American Pediatric 
Society adopted the classification, as presented to them by their commit- 
tee. This classification must be understood to be merely provisional, and 
is for the purpose of aiding those who are interested in this subject to 
work with uniformity. 

At the same time it is believed that it is a great advance upon the 
unmeaning and misleading nomenclature now current. Since the meet- 
ing of the Pediatric Society in 1894 certain diseases, such as cholera in- 
fantum and tubercular ileo-colitis, have been transferred from the gastro- 



772 PEDIATRICS. 

enteric to infectious diseases as manifestly being general rather than 
local. 

On examining the classification (Table 72, page 773) it is seen that, 
whenever the etiology has been definitely determined it is made to desig- 
nate the disease, but the true etiology is still unknown in so many cases 
that other terms have of necessity been used, the names simply repre- 
senting the extent of the knowledge we have of the especial disease. 

The diseases of the gastro-enteric tract may, on this basis, be divided 
into diseases of the stomach (gastric), diseases of the intestine (enteric), and 
the disturbances which arise from animal parasites. * The diseases are 
then divided into those which arise from developmental, those which 
arise from functional, and those which arise from organic causes. The 
organic diseases are subdivided into non-inflammatory and inflammatory, 
and the functional and organic diseases into acute and chronic. 

General Treatment. — In the treatment of these diseases we should 
endeavor to carry out four rules : (1) to combat the nervous symptoms 
if causative ; (2) to dislodge the bacteria as quickly as possible, perhaps 
by laxatives and irrigation ; (3) not to introduce into the gastro-enteric 
tract for a certain period food which may prove a favorable culture- 
ground for the bacteria, since it has been shown that where the food is 
sterile when it enters the gastro-enteric tract it is quite effective in re- 
ducing the number of bacteria in the intestine ; (4) to introduce such 
drugs into the gastro-enteric tract as may, by their anti-fermentative and 
germicidal powers, diminish the action of or destroy the bacteria. This 
last rule is, however, very difficult to carry out, and, with our present 
knowledge of drugs and their administration, practically impossible. It is 
true that we know that subnitrate of bismuth is an anti-ferment, and that 
it reaches the part of the enteric tract which we know to be most affected 
in enteric disturbances characterized by fermentation. Fig. 160 shows the 
intestine of an infant, given to me by Dr. Holt, to illustrate this point, to 
whom bismuth had been given, and in whom at the autopsy the bismuth 
was found thickly coating the mucous membrane of the small intestine, 
and also appearing in the large intestine. It is, however, questionable 
whether in any case the attempt to kill the bacteria by the internal admin- 
istration of drugs has been successful. Preparations, such as salol, which 
are known to be broken up into their carbolic acid components on reach- 
ing the intestine, cannot with safety be given to the infant in doses large 
enough to kill the bacteria, for in such doses there may be serious results 
from poisoning. We can, however, possibly, by means of these germi- 
cidal drugs, produce a condition in the intestine which, though not con- 
ducive to the death of the bacteria, may yet be so unfavorable for their 
growth as to- aid our treatment when we are endeavoring to dislodge them. 
Nothing definite has, however, as yet resulted from using drugs for this 
purpose, and, so far as I can judge, the danger of treating infants or young 
children in this way is greater than the good that may result from it. 



DISEASES OF THE STOMACH. 



773 



TABLE 72. 
Diseases of the Gastro-Enteric Tract. 



r , ^ f (a) Malformations. 

f I. Developmental. < ) f 

{ (b) Malpositions. 



A. GASTRIC. \ 



II. PUNCTIONA] 



(a) Acute 



(1) Nervous vomiting 

(2) Cyclic vomiting. 

(3) Indigestion. 



Central-Reflex. 



I III. Organic 



(b) Chronic Indigestion. 

(c) Eliminative. 

. , „ T a [ (1) Mechanical. 

(a) Non-Inflamma- ,_, T „ 

< (2) I leers, 

torv. ,«*-»., 

I (3) New Growths. 



I (b) Inflammatory. 



T ^ ( (a) Malformations. 

f I. Developmental. < ; ' _, . 

I (b) Malpositions. 



( (a) Acute, 



(1) Acute Gastritis . < 

(2) Chronic Gastritis . Catarrhal. 



(a) Catarrhal. 
(6) Corrosive. 
(c) Pseudo-membra- 
nous. 



II. Functional 



B. ENTERIC, i 



(b) Chronic 



(c) Eliminative. 



(1) Nervous. . . . 

(2) Indigestion . . 

(1) Nervous. . . . 

(2) Indigestion . . 

(3) Incontinence. 

(4) Constipation . 

(1) Fermental . . 



III. Organic 



f (a) Non-Inflamma- I (2) Me chanical 
torv. 



; (3) New Growths, 
f (a) Proctitis. 
I (6) Inflammatory. \ {b) Appendicitis 
I (c) Ileo-Colitis . 



. Central-Reflex. 

f (a) Duodenal. 
1 (b) Intestinal. 

. Central-Reflex. 

f (a) Duodenal. 
I (b) Intestinal. 



Atonic-Spasmodic. 



Acid-Albuminous. 

f Dilatation of Colon. 

Volvulus. 

Intussusception. 

Hernia. 

Fissure. 

Prolapse. 

Polypi. 

Hemorrhoids. 
^ Fistula?. 



C. ANIMAL PARASITES. 



( (a) Acute. 
I- (6) Chronic, 
f (a) Acute. 
1 (6) Chronic. 



DISEASES OF THE STOMACH. 

GENERAL CONSIDERATIONS. — From what has been said it will 
be understood how difficult it is to make a differential diagnosis between 
gastric and gastro-enteric disturbance. The only symptom which defi- 
nitely shows the stomach to be involve^, whether from reflex, functional, 
or organic conditions, is vomiting, and, as we know that in many cases 
vomiting is caused primarily by disturbance of the intestine, we really 
have no symptom which represents gastric disease alone. The difficulty 



774 PEDIATRICS. 

of locating disease in the stomach is rendered still greater by the fact that 
serious organic lesions may exist in the stomach without any symptoms 
whatever, whether of vomiting, pain, or tenderness. We must, there- 
fore, be exceedingly cautious in making a diagnosis of diseases of the 
stomach. 

Diseases of the stomach may arise from developmental, functional, or 
organic causes. 

I. DEVELOPMENTAL. — Under developmental affections of the 
stomach are included malformations and malpositions. A malformation of 
the stomach may be represented by a narrowing of either the cardiac or 
the pyloric orifice, or by constrictions in various parts of the ventral cav- 
ity, which are known as hour-glass contractions. A malposition of the 
stomach may be met with in various places, one of which is in the 
thoracic cavity. These malpositions, however, are exceedingly rare, and 
of pathological rather than of clinical interest, as the diagnosis can scarcely 
be made during life. Congenital stenosis of the pylorus in infants, re- 
sulting fatally in a few weeks or months, has been described, but its 
existence has been questioned. 

II. FUNCTIONAL. — The functional diseases of the stomach play a 
great role in infants and in young children. They may be of an acute or 
a chronic variety, or may be what I have spoken of as eliminative. Acute 
functional gastric symptoms may be produced by a number of causes, 
but in general they are to be understood as arising from a nervous con- 
dition represented by vomiting or by a disturbance of the function of 
digestion, which had best be spoken of, until more is known of the sub- 
ject, as simple indigestion. 

ACUTE NERVOUS VOMITING. 

Vomiting may arise from gastric or from intestinal irritation in many 
diseases, such as tubercular meningitis, from heat, cold, fright, and from 
other causes. Direct irritation, from foreign bodies, food, or otherwise, 
may produce a reflex form of vomiting. In these cases the cause, if pos- 
sible, should be removed, and the stomach given a complete rest until the 
nervous disturbance has subsided. As a rule, no internal remedies are 
indicated in these cases, except an emetic when the vomiting arises from 
the reflex causes just described, or, if necessary, lavage. 

CYCLIC OR RECURRENT VOMITING. 
There is one form of vomiting which is of such importance that it 
must be spoken of as a disease by itself. It has been called cyclic or re- 
current vomiting. It has not been shown that it is a primary disturbance 
of the stomach. In fact, in many cases it is possible that the source of 
irritation is entirely outside of the stomach, and perhaps connected with 
the great sympathetic ganglia, such as the solar plexus, or it may eventually 
be proved to be of toxic origin and be placed under the eliminative class. 



Fig. 160. 




Colon showing presence of bismuth which had been given by the mouth. 
(Page 772.) 



DISEASES OF THE STOMACH. 775 

Etiology. — The inciting cause of the vomiting in most cases is obscure, 
but is evidently very varied. It does not seem to be produced especially 
by errors of diet, but, on the contrary, occurs in children whose diet has 
been most carefully regulated. Undue exposure to cold, fright, and ex- 
citement all appear to me to have sometimes an etiological influence on 
the disease. Recent investigations by Marfan on acetonemia and by Edsall 
point strongly to acid intoxication as a factor in the etiology. Edsall has 
detected the odor of acetone in the urine immediately before an attack, 
and asserts that it disappears with the cessation of vomiting. He also 
found oxybutyric and diacetic acids in conjunction with acetone. This 
form of vomiting may occur at any age. I have met with cases in young 
infants and throughout the whole period of childhood. The attacks may 
occur not only in delicate but in vigorous children. 

Symptoms. — The attack is very apt to come on suddenly, the child 
being previously in good health and not having shown any digestive dis- 
turbance. The period over which the disease extends and the intervals 
of the vomiting during the attack vary considerably, but in those cases 
which have come under my notice they are somewhat as follows. The 
child, without any especial warning, begins to vomit, and at first the 
vomitus will simply be the remains of food which still happen to be in 
the stomach. It will continue to vomit quite regularly every fifteen or 
thirty minutes. This may last for ten or twelve hours ; the intervals then 
grow longer, and sometimes the vomiting will cease for twelve or fifteen 
hours, and then begin again. Occasionally a little mucus appears in the 
vomitus. As the disease progresses, a slight amount of bile usually ap- 
pears in the vomitus. A very prominent symptom is thirst, the child 
crying continually for water, and vomiting it soon after it is taken. As a 
rule, the temperature in these cases is normal or subnormal. The pulse 
varies, but is very apt to be slow, sometimes intermittent, and may become 
weak. After the first twenty-four hours the child emaciates rapidly, looks 
very ill, and becomes apathetic. 

Unless the disease is unwisely treated by endeavoring to introduce 
food or drugs into the stomach, it will usually prove to be self-limited, 
and will run its course in two or three days. In some cases the length 
of the attack is much shorter, being comprised within twenty-four hours, 
while in others it may last for many days. The recovery is often as 
sudden. As soon as the vomiting has stopped, the appetite returns ; there 
are no special symptoms of indigestion ; the child takes its food well, and 
the emaciation disappears rapidly. Relapses occasionally take place. 

Diagnosis. — The diagnosis of this form of vomiting is often difficult, 
more on account of a lack of sufficient knowledge concerning the dis- 
ease than from much evidence of the existence of the diseases which it 
is supposed to simulate. Thus in early infancy acute persistent vomit- 
ing may be the first symptom of a beginning tubercular meningitis. In 
these cases an examination of the abdomen should be made at once, in- 



776 PEDIATRICS. 

eluding a rectal examination. This is necessary in order to exclude such 
sources of vomiting as intussusception and appendicitis. The absence of 
any marked increase in the temperature and a careful examination of the 
thorax will in most cases exclude the sudden onset of some pulmonary 
disease or of the acute infectious diseases. The disease which is most 
commonly suspected in these cases is tubercular meningitis. In cyclic 
vomiting the face and general appearance of the child indicate nausea 
rather than the apathy which would be present in tubercular men- 
ingitis. The mind also, in contradistinction to what takes place in the 
latter disease, is clear, the child remaining quiet merely because it is ex- 
hausted. The great thirst which has been already mentioned as being 
present in persistent vomiting also aids materially in the differential diag- 
nosis from tubercular meningitis. The sudden onset of the vomiting in a 
previously healthy child in the middle period of childhood is quite differ- 
ent from the slow progress and the occasional vomiting of a cerebral type 
met with in tubercular meningitis. The theory of acid intoxication points 
to the examination of the urine for acetone, diacetic acid, and oxybutyric 
acid as important aids to diagnosis. 

After the first twenty-four hours, this disease is readily differentiated 
from attacks of simple indigestion, for, when the vomiting arises from 
indigestion, the stomach is speedily relieved, and the vomiting does not 
continually recur without apparent cause, as in cyclic or persistent 
vomiting. 

Cyclic vomiting is also very commonly diagnosticated as acute gastric 
catarrh, but in the latter disease the heightened temperature, coated tongue, 
pain, and tenderness in the epigastrium will, after the first twenty-four 
hours, allow us to differentiate the two diseases. 

Prognosis. — The prognosis varies according to the age of the individual 
affected. In young infants, especially in those whose vitality is weak, it 
may prove to be a very serious disease, from the exhaustion which inva- 
riably arises in the first twenty-four hours. The rule is that the younger 
the individual the more prostrating and serious is the disease. Even older 
children are at times so prostrated by the continuous vomiting that grave 
doubts are often entertained as to their ultimate recovery. In general, 
however, the prognosis in these cases is good, and I have never seen the 
disease result in death. 

Treatment. — The treatment is essentially starvation during the first 
twenty-four hours. The child should be kept perfectly quiet in a dark- 
ened room. If after twenty-four hours the vomiting still continues, or 
even before, if there appears to be much exhaustion, or if the child is rest- 
less and sleepless and has an intermittent pulse, hydrate of chloral and 
bromide of potassium, dissolved in brandy and water, should be given by 
the rectum. These are intended to procure sleep and to stimulate the 
nervous centres. As a rule, however, the child is quiet, and sleeps in the 
intervals of vomiting, and, as the disease usually attacks an infant or a 



DISEASES OF THE STOMACH. 777 

child who has been perfectly well, cardiac weakness is not commonly 
shown in the first forty-eight hours. No food and no drugs should be 
given by the mouth. At the very beginning of an attack very large 
doses of bicarbonate of soda should be given to combat the acid intoxi- 
cation of the blood. One to two drachms, according to the age of the 
child, well diluted and in divided doses, should be given by rectum until 
the urine shows an alkaline reaction. The dose should then be diminished 
and given in quantities just sufficient to maintain the alkaline reaction. 
After from twenty-four to forty-eight hours, small enemata of peptonized 
milk can be given, and when the disease appears to have run its course, 
as it often does in three or four days, small quantities of a carefully modi- 
fied alkaline milk can be tried cautiously by the mouth. A mistake is 
usually made in the treatment of the disease in feeding by the mouth too 
early. 

The following cases are illustrative of this disease . 

An infant, eight months old, strong and healthy, had always been fed on the milk 
of a wet-nurse. Without any previous symptoms he began to vomit, and continued to 
vomit every fifteen minutes for twelve hours. The intervals then became longer, and 
the vomiting ceased entirely on the third day of the attack. During the attack he 
emaciated rapidly, so that he seemed to be in the last stages of some wasting disease. 
He lay perfectly quiet and slept in the intervals of the vomiting. His mind was clear. 
His temperature was subnormal, and his pulse weak and intermittent. He was treated 
by rectal enemata of brandy, peptonized milk, and bromide of potassium. 

He had several attacks of this kind in each of the following years of his life until 
he was five or six years old, when he would sometimes go for six months or a year with- 
out an attack. As he grew older the attacks became less severe, and when he was ten 
years old they ceased entirely. 

Another case was that of a girl twenty-two months old, who was perfectly well 
until the vomiting began. Her pulse was slightly accelerated at first but gradually be- 
came slow and intermittent. Her temperature was normal. During the first four 
days of the attack the vomiting was almost continuous, and she became so weak and 
exhausted on the fourth day that it was feared she might die suddenly. There were 
great restlessness, dilated pupils, throwing of the head backward, slow pulse, and 
normal respirations. The emaciation was rapid. The urine was scanty. On the fifth 
day, the vomiting having continued, she fell into a state of collapse, the pulse was 
hardly perceptible, her countenance was ghastly and her extremities were cold. At 
one time after a severe attack of vomiting she became cyanotic, and was almost stifled 
by tenacious mucus. Some of this mucus entered the larynx during the attacks of 
vomiting, so that it seems as though her life was saved a number of times by the 
prompt action of an experienced nurse. On the sixth day the vomiting grew less, and 
on the seventh day it ceased. She was not, however, able to be up and about until 
the eleventh day, and was not fully well until the third week from the time that she 
was attacked. The treatment in this case was the same as in the one just described. 

GASTRALGIA. 

In certain children, usually of a nervous temperament or in a debili- 
tated condition, attacks of pain, seemingly referred to the epigastrium, 
seem to occur which are not accounted for by the more common sorts of 



778 PEDIATRICS. 

pain in this region, such as in cases of vertebral caries and in indigestion, 
from which the pain of gastralgia is to be differentiated by the rules laid 
down in speaking of these other diseases. It is possible also that dia- 
phragmatic pleurisy may cause a pain of this kind, and it must therefore 
be borne in mind in the diagnosis. These attacks are apparently neu- 
ralgic and produce symptoms of acute gastric indigestion, and, in severe 
cases, of obstruction. They should be treated during the acute attack 
with rest in bed, hot applications to the abdomen, deprivation of food by 
the mouth, and in extreme cases with a dose of tinctura opii camphorata 
1 to 1.2 c.c. (8 to 10 minims). Between the attacks the general health 
should be improved by tonics and good hygiene. As malaria may be a 
source of the attacks, the plasmodium should be looked for, and if neces- 
sary the case should be treated with quinine, and later, when necessary, 
with arsenic in the form of Fowler's solution. 

ACUTE GASTRIC INDIGESTION (Acute Dyspepsia ). 

By indigestion we mean a disturbance of the gastric secretions inter- 
fering with the function of the stomach to such a degree as to cause mor- 
bid symptoms. Exactly what this disturbance is in infants and young 
children has not been clearly proved. The cause of acute indigestion in 
infants, and in almost every case in young children, is the food which is 
given to them. This is especially noticeable in the first year. The ages in 
which indigestion most frequently occurs in this period are, first, in the 
early days of life, when the • equilibrium of the breast-milk has not been 
established ; second, in the middle of the first year, when the breast-milk 
is so apt to be replaced or supplemented by some other food ; and, third, 
at the end of the year, when entirely new articles of diet are usually given 
to the infant. 

Symptoms. — The symptoms of acute indigestion are extreme pallor, 
nausea, eructations of gas, a general appearance of discomfort, due prob- 
ably to the pain induced by the development of gas in the stomach, with 
its resulting distention, and finally vomiting. If the diet is exclusively of 
milk, the vomitus will usually contain large curds of the coagulated pro- 
teids. In connection with the gastric disturbance there is commonly con- 
stipation, although sometimes there may be a relaxed condition of the 
bowels. The faecal discharges accompanying these attacks are of an ab- 
normal color, usually a mixture of green, white, and yellow, and of sour 
odor. There is little or no fever. At times the symptoms are so severe 
that the infant looks as though it were going to die. In rare cases, also, 
reflex symptoms of a serious aspect may arise, such as have been de- 
scribed under asthma dyspepticum (page 946). 

Diagnosis. — Sometimes the diagnosis is obscured by the absence of 
vomiting, but the pallor and nausea are usually of sufficient prominence 
to allow us to decide that the seat of the disturbance is in the stomach. 
The differential diagnosis is most important between this condition and 



DISEASES OF THE STOMACH. 779 

acute gastric catarrh. Acute indigestion is much more common, its dura- 
tion is shorter, there is less fever, tenderness is unusual, and the response 
to treatment is much more rapid and evident. 

Prognosis. — The prognosis of acute gastric indigestion is in most cases 
good, but in infants whose vitality is extremely low, or in those that are 
debilitated by some wasting disease, these attacks are of serious import, 
and may prove fatal. 

Treatment. — The treatment of acute gastric indigestion is to empty 
the stomach, either by washing it out or by the administration of warm 
water. A mild laxative should be given in order to clear away the undi- 
gested food, and the diet should be regulated. The laxative may be one 
or two teaspoonfuls of castor oil, .007 to .006 gramme (one-eighth to one- 
tenth grain) of calomel for four or five doses, or a teaspoonful of liquid 
magnesia. If the food has been human milk an analysis of the milk 
should be made at once, and the milk should be modified according to the 
rules which have already been given. If the infant is being fed on an im- 
properly modified milk, or if improper food of any kind has been given to 
it. a recurrence of the attacks can easily be obviated by a modification of 
the elements of the food which seem to have produced the disturbance. 
Thus, in a number of cases I have found that whenever the infant's food 
was modified so as to raise the percentage of the sugar above 5, acute in- 
digestion followed. In like manner in certain cases the percentage of the 
fat had to be reduced to 3, or perhaps 2.5, and the proteids even as low 
as 0.45, for a number of weeks until the digestive function of the stomach 
became normal. As relapses are common where food in any form is 
given too soon after the attack, nothing should be given excepting boiled 
water with a few drops of brandy for six or eight hours. 

In older children the symptoms are similar to those which have just 
been described, and the diagnosis and treatment the same as in the infant. 
After allowing the stomach to rest, a recurrence of the attack is best pre- 
vented by at once placing the child for several days on an exclusive diet 
of a milk modified in such a way as to contain a percentage of from 2 to 
3 of fat, 5 to 6 of sugar, 1 to 2 of proteids, and 10 of lime-water. 

CHRONIC GASTRIC INDIGESTION (Chronic Dyspepsia). 

If the attacks of acute indigestion are allowed to occur frequently from 
lack of proper treatment, a subacute or chronic form of the disease 
develops. 

Symptoms. — In infants the symptoms of chronic indigestion are much 
less severe than those of the acute form. The infant is apt to vomit after 
taking its food, to be restless, fretful, and either to lose in weight or not 
to gain. Its sleep will be very much disturbed, apparently by pain from 
flatus. In chronic indigestion the bowels are apt to be constipated, but 
this is not always the case. The chronic indigestion of older children 
presents a somewhat different aspect. The temperature is at times some- 



780 PEDIATRICS. 

what heightened. The tongue is apt to be coated, and the breath to have 
an odor. These children do not vomit so frequently as do infants. They 
lose in weight, become fretful, and get tired easily. 

Treatment. — I have seldom found the use of any especial drug to be 
of much benefit in these cases of chronic indigestion. In quite a number 
of cases of both acute and chronic indigestion, before any food is intro- 
duced into the stomach it is often wise first to wash out the stomach 
thoroughly (lavage). This procedure is especially indicated if the indi- 
gestion has produced continuous vomiting. 

The technique of washing out the stomach is very simple. A soft 
rubber catheter with a double eye, No. 21 French scale, for infants under 
six months, and No. 25 for older children, is attached by means of a piece 
of glass tubing 7.5 cm. (3 inches) long to another rubber tube which is 
50.5 cm. (20 inches) long attached to a funnel, preferably of hard rubber, 
and capable of holding from 90 to 120 c.c. (3 or 4 ounces). The infant 
is seated upright in the nurse's lap, with its head inclined forward and 
resting on the nurse's arm. Its arms are controlled by a towel pinned 
around them. The catheter, having been Avet with warm water, is easily 
passed over the base of the tongue into the stomach. As there is often 
considerable gas in the stomach, the funnel should be raised as high as 
possible above the infant's head, in order that the gas may pass out from 
the stomach. From 90 to 120 c.c. (3 or 4 ounces) of sterilized water 
should be poured into the stomach by means of the funnel. The funnel 
is then depressed below the level of the stomach, and the gastric contents 
will in this way be siphoned out. As the curds are often too large to 
pass through the eye of the catheter, a number of washings will often be 
necessary to break them up. By washing out the stomach not only are 
the irritating substances which are producing the indigestion removed, and 
the mucous lining of the stomach left free to recover its normal condition, 
but it is also possible to have a chemical examination of the contents 
made. Clinically, however, the latter is not necessary, although it is of 
great interest physiologically. No food should be introduced into the 
stomach for at least two hours after the washing. The washing of the 
stomach is almost entirely free from danger, and,*in addition to being an 
important part of the treatment of indigestion, is often of great use where 
poisonous substances have been swallowed. 

This method of treating disturbances of the stomach is more valuable 
in young infants than in older children, because the latter resist so vigor- 
ously that the remedy is often of more harm than good. The tube can, 
however, usually, even in older children, be introduced by aid of the 
ordinary gag which is used for intubation. Two assistants are usually 
necessary in introducing the tube in older children, while in infants one 
assistant is sufficient. In some cases it is found necessary to introduce 
the tube through the nose. The tube should be passed into the throat 
rapidly, since the gagging and vomiting occur chiefly when the tube 



DISEASES OF THE STOMACH. 781 

touches the pharynx. There is usually an escape of gas or gastric con- 
tents as soon as the tube enters the stomach. 

When the inflow of water through the tube is shown to be too rapid, 
by the fact that the infant holds its breath too long, or by its crying, vom- 
iting, or coughing continuously, the flow should be stopped for a short 
time. Care must also be taken not to introduce the catheter too far into 
the stomach, as it may bend on itself and interfere with the flow of the 
returning water and gastric contents. If the gastric contents are expelled 
along the side of the tube rather than through it, the tube should be with- 
drawn until the vomiting has ceased. There seems to be no danger of 
passing the tube into the larynx, or of perforating the stomach with it. 

Lavage is contra-indicated when there is cardiac disease or any severe 
pulmonary disturbance, and when the introduction of the catheter con- 
tinues to excite vomiting it should be used with extreme caution. The 
fact that the infant is in a feeble condition is not a contra-indication to this 
treatment. 

In connection with lavage it is well to speak of forced feeding (gavage) 
in the treatment of infants and young children. In cases of acute and 
chronic indigestion, and also where a catarrhal condition of the stomach 
is present, the infants at times refuse to take any food whatever. This 
does not occur merely when the disturbance is in the stomach ; I have 
frequently met with it in severe cases of all kinds of disease. In a num- 
ber of instances, when the infants would probably have died of starva- 
tion had not gavage been employed, this means of providing for their 
nourishment has been very successful. Forced feeding may sometimes 
have to be employed for a number of days, and even weeks, before the 
child will of itself swallow again. 

The technique of gavage is similar to that of lavage. The same appa- 
ratus is employed, and the child should be placed flat on its back in bed 
or held half reclining. The head is held by an assistant. The catheter 
should be passed into the stomach rapidly, the funnel raised up in the air 
for a few minutes in order that the gas may escape, and the amount of 
food adapted to the age of the child should then be poured into the funnel. 
As the last of the food disappears from the funnel, the catheter is pinched 
tightly and quickly withdrawn. This precaution is important, in order 
that the pharynx shall not be irritated either by the slow withdrawal of 
the catheter or by the trickling of the remains of the fluid, as vomiting 
may in this way be excited. 

One of the advantages which has resulted from the use of the stomach- 
tube is the knowledge we have acquired of the time which the food re- 
mains in the stomach at different ages. Thus, it has been found that during 
the early weeks of life the stomach is nearly emptied in an hour, while 
in older infants two hours are required for the same process. This knowl- 
edge is especially valuable Avhen we are regulating the intervals of feeding 
in premature infants, and in infants during the first six months of life. 



782 PEDIATRICS. 

When other means can be employed, they are preferable to the 
stomach-tnbe, but in many instances when infants or children refuse to 
take their food the simplest way of forcing it upon them is to pinion the 
arms with a towel and have the nurse hold the child half reclining in 
her lap. Sometimes an assistant is needed to hold the head, but this is 
often unnecessary. Simply pressing the child's nostrils with the thumb and 
finger will cause it to open its mouth, and the food can then be poured in 
with a spoon, or introduced by the Breck feeder or by means of a dropper 
with a large end. 

A child two and one-half years old, who has recently been under my care, for 
several weeks would not take any food without being forced to do so. Although this 
child was very ill with pneumonia, involving both lungs, it was fed every two or 
three hours, night and day, by this method. After the first two or three feedings it 
did not resist, and the nose did not have to be pinched, all that was necessary being- 
to threaten to do so. 120 c.c. (4 ounces) of milk were, after a little practice, intro- 
duced by means of the dropper into the child's stomach in five or six minutes. 

I have found that the most speedy cure of chronic indigestion is to 
give the child a carefully modified alkaline milk. In some cases it will be 
necessary to reduce the fat or sugar, in others the proteids, but in every 
case, as soon as it is determined which of these elements in full strength 
does not suit the individual digestion, an improvement in the symptoms 
will soon follow the reduction of the percentage of that element. In some 
cases peptonization of the milk after modification is found valuable. After 
the indigestion has been relieved by this means, other articles of diet 
adapted to the age of the child can gradually be added. 

In addition to the direct treatment of the stomach, the intestinal dis- 
turbance which almost always accompanies the gastric indigestion should 
be relieved by occasionally giving a dose of some mild laxative, preferably 
one of the salts of magnesia, such as the citrate. This latter treatment is 
indicated not only for children, but for young infants, because, when there 
is gastric indigestion, the undigested food which passes into the duodenum 
is a prolific source of intestinal disturbance. This, by adding to the dis- 
comfort of the child, weakens it, and tends to prolong the gastric indiges- 
tion. In the more intractable cases, small doses of bismuth, soda, or 
dilute hydrochloric acid may be useful. Bismuth is indicated for allaying 
irritation and counteracting fermentation. Soda and hydrochloric acid 
have to be used somewhat empirically, as we know so little about the 
chemical conditions present. After the more prominent gastric symptoms 
have disappeared, considerable benefit can be obtained by using small 
doses of the tincture of nux vomica for several weeks. 

ELDVONATTVE. 

In the eliminative class of diseases of the stomach, certain morbid and 
irritating substances are supposed to enter the stomach, as though it were- 



DISEASES OF THE STOMACH. 783 

an excretory organ, and may possibly explain many of the obscure gastric 
symptoms which arise in early life, but at present our knowledge of this 
class of cases is so slight and indefinite that it need only be alluded to. 

III. ORGANIC. — The organic affections of the stomach may be di- 
vided into non-inflammatory and inflammatory. They are very rare in 
comparison with the functional diseases. 

A. Non-Inflammatory. — The non-inflammatory conditions of the stom- 
ach comprise a diminution in the size of the organ, mechanical dilatation, 
ulcers, and new growths. 

CONTRACTION OF THE STOMACH. 

In certain cases the gastric capacity of the stomach is decidedly dimin- 
ished. This diminution in size, as a rule, depends upon a lack of use, 
such as occurs in infantile atrophy. Sufficient food to fill the stomach is 
not taken, and in this Avay the stomach is not called upon to perform its 
normal work. In cases, also, in which there is continuous vomiting, this 
same lack of use may produce a diminution in the size of the stomach. 
These cases are of pathological rather than of clinical interest, as they can 
seldom be diagnosticated, and their treatment is essentially that of the 
especial disease to which they are secondary. 

DILATATION OF THE STOMACH. 

A moderate dilatation of the stomach is rather more common in 
infancy than in older children. The higher degrees of dilatation are rare. 
It may rarely arise from some malformation, such as a stenosis of the 
pylorus, but in most cases is the result of errors in feeding. It is more 
apt to occur when the infant is not nursed, unless especial care is taken 
to give the infant the quantity of food which is adapted to its age and 
gastric capacity. When the infant is nursed, the breast seems to provide 
the amount of food which is suitable. Dilatation from errors in feeding 
may be caused by the fact that the food is not adapted, either in quality 
or in quantity, to the age of the individual infant. When the quality is 
at fault, the nutrition of the tissues of the stomach is interfered with, and 
its walls become weak, and are thus more easily distended by the gas 
which results from the abnormal changes in the food. In this way dila- 
tation occurs. This class of cases is notably represented in the disease 
rhachitis, in which dilatation of the stomach takes place very readily. 

When the quantity of the food is not properly adapted to the size of 
the stomach, dilatation can take place in even a healthy infant, so that 
the careful regulation of the amount of food which is given at each feeding 
during the first year of life is most important. 

Pathology. — The pathological condition which exists in cases of gastric 
dilatation is well represented in Fig. 161. 

This stomach was taken from an artificially fed rhachitic infant, seven months old, 
who died under my care at the Boston City Hospital. The gastric capacity in this case 



784 



PEDIATRICS. 



was 300 c.c. (10 ounces), which corresponds to the gastric capacity of an infant twelve 
months old. The shape of the stomach is very significant of the symptoms. 

The lesser curvature is not much altered, while the greater curvature is very much 
increased. The pathological condition of the tissues in these cases is such as would be 



Fig. 161. 




Dilated stomach. Rhachitic infant, 7 months old (Actual size.) 

expected from general malnutrition. In such diseases as rhachitis there is a stretch- 
ing of the muscular fibres, as well as an atrophied condition of the entire gastric walls. 



Symptoms. — The symptoms of dilatation of the stomach are essentially 
those of chronic indigestion. Vomiting is quite frequent, and continues 
until the stomach has been entirely emptied, when a period of relief comes, 
to last until fresh irritation arises from another supply of food. Abdomi- 
nal pain, flatulence, and general discomfort are prominent symptoms. 



Rapid loss in weight and emaciation also occur, 
infants, convulsions may arise, apparently due 



In some cases, in young 
to the reflex disturbance 



DISEASES OF THE STOMACH. 785 

which is produced. There are usually considerable thirst and loss of ap- 
petite. When the dilatation is of a high grade, the vomiting may occur 
only after considerable intervals, — twenty-four to forty-eight hours. — 
during which time the food does not pass out through the pyloric orifice 
to any degree, but collects in the stomach. 

Under normal conditions the stomach is somewhat tubular in shape 
and oblique in position. The food thus easily passes through the cardiac 
to the pyloric orifice. In dilatation of the stomach, on the contrary, the 
greater curvature is so much increased and depressed below the level of 
the pyloric orifice that a pouch is formed. The food, collecting in this 
pouch as though if were at the bottom of a well, has to be practically 
pumped, by the contraction of the muscular Avails, up to and through the 
pyloric orifice. The already weakened stomach thus has to perform work 
for which it is not fitted, and finally is relieved by spasmodic vomiting. 
When only the small amount of food adapted to their normal gastric 
capacity is given to young infants whose stomachs are dilated, a large space 
of empty stomach is left above the level of the liquid which has entered 
the stomach. This creates a feeling of emptiness and general discomfort, 
so that the infant appears to be hungry when, in fact, it is only suffering 
from the feeling of incomplete filling of the stomach. 

On inspection the abdomen is seen to be distended and tense, and on 
percussion to be highly tympanitic in its upper part. Succussion is not 
an especially valuable diagnostic sign in dilatation of the stomach. Suc- 
cussion is so frequently found in many conditions, and is so likely to be con- 
founded with that which occurs in the colon, that it cannot be relied upon. 
The outlines of a normal stomach when somewhat distended vary so much 
in infancy that the results of percussion are often very misleading. When, 
however, the tympanitic resonance is found to extend below the line of 
the umbilicus, we may suspect that we are dealing with gastric dilatation, 
but even then it is uncertain whether it is the gastric tympany which we 
have obtained. In infancy the cardiac end of the stomach is so slightly 
developed that any great increase in the area of gastric resonance to the 
left is an important aid in making the diagnosis. 

Diagnosis. — The differential diagnosis is to be made chiefly from dila- 
tation of the colon. In many cases when the colon is dilated it is impos- 
sible to determine whether the stomach is also dilated, since under these 
circumstances the colon can almost completely cover a largely dilated 
stomach. In cases in which the diagnosis is uncertain, a valuable means of 
determining the presence of dilatation is artificial distention. This can be 
done without harm or much discomfort to the child by filling the stomach, 
several hours after the last feeding, by gas generated by giving part of a 
seicllitz powder in divided portions, by air through a stomach-tube, or pref- 
erably by water. 

The gastro-diaphane, recommended by Koplik, can also be used as a 
method of diagnosis. 

50 



786 PEDIATRICS. 

Prognosis. — If the dilatation is due to congenital stenosis of the 
pylorus the prognosis is very unfavorable. In other cases the prognosis 
depends upon whether the condition arises from improper amounts of 
food or from some disease, such as rhachitis. In the former class the 
prognosis is good, and the stomach under a proper regulation of the diet 
soon resumes its natural size. In the second class it is not so good, and, 
as a rule, the stomach will remain more or less distended until the disease 
which causes the dilatation has been cured. 

Treatment. — If the case is an obstinate one, lavage is an important 
part of the treatment. In many cases, however, good results are 
obtained simply by regulating the quality and quantity of the food. 
When the food is first given in the proper amount it Avill not fill the 
stomach nor satisfy the demands of the infant. Under these circum- 
stances the infant will be very restless, and will often cry almost continu- 
ously from the time of one feeding until the next. The nurse must be 
made to understand that these signs of discomfort are liable to last for a 
number of days, until the stomach has more nearly resumed its normal 
size, and that an additional supply of food must not be given to the infant 
because it cries for more. 

The following case illustrates dilatation of the stomach as it occurs in the first year 
of life. A male infant four months old was well and strong at birth. It was not nursed, 
but was fed on a mixture of milk, cream, and water. It was unusually vigorous, and is 
reported to have never been satisfied with the small quantities of food suitable to its age. 
When it was three weeks old it was given 150 to 180 c.c. (5 or 6 ounces) at each meal. 
Somewhat later, in its second and third months, it gradually developed symptoms of in- 
digestion, and when I was called to see it was in a very serious condition. It had been 
having frequent and prolonged convulsions. At times when it was in the convulsions it 
would fall into a state of collapse, the pallor of its face would be extreme, and it would 
look as though it were dying. On examination nothing abnormal was found in the thorax. 
The entire abdomen was found to be distended, especially in the upper part, where the 
gastric tympany was pronounced and easily marked out by percussion. The percussion 
showed the stomach to be dilated, and to extend below the line of the umbilicus and far 
to the left of the median line. 

The infant was given small amounts of food at frequent intervals. For the first 
two or three, days it cried and screamed for more food, but the convulsions ceased, its 
general condition improved, by the end of the week the distention of the stomach had 
subsided very markedly and the infant had become tranquil, and this time there was no 
recurrence of the symptoms. 

A second case was that of a colored boy six years old. He was markedly rhachitic. 
He was reported to have been in fair health, though delicate, until one month previous 
to entering the hospital, when he began to have persistent vomiting. He had lost greatly 
in weight, had been very restless at night, and he had continual borborygmi. 

Physical examination showed marked abdominal enlargement. On percussion the 
gastric tympany was found to extend downward as far as the umbilicus, 7.8 cm. (3 inches) 
to the right of the median line, and 10.4 cm. (4 inches) to the left. In the figure the 
line of percussion which represents the greater curvature of the stomach is marked with 
white dots. As the resonance of the colon was also exaggerated in this case, and as its 
differentiation from that of the stomach was somewhat difficult because it evidently over- 
lapped the lower border of the stomach, an endeavor was made to eliminate this obstacle 



DISEASES OF THE STOMACH. 



787 



to diagnosis by mechanical means. The child was given one-half a seidlitz powder dis- 
solved in water. The other half, which had also been dissolved in water, was next 
swallowed. The child showed no signs of discomfort, and stated that he did not feel any 
pain or any more tenderness in the epigastrium than before the powders were taken. 



Ftg. 162. 




Dilatation 



The outline of the distended stomach could be fairly well seen, and on percussion the 
line of the greater curvature was found to be 2.5 cm. (1 inch) below the line of the 
umbilicus, the colon having been pushed out of the way by the distended stomach. 
I have indicated the line of greater curvature by a broad white line. 

(Subsequent history.) In this case it was not found necessary to wash out the 
stomach more than once or twice, for as soon as small amounts of food were given at 
frequent intervals the vomiting ceased and the stomach gradually resumed its normal 
size. At the end of two months the child left the hospital free from any abnormal gas- 
tric symptoms. 

ULCERS. 

Ulcers of the stomach in infancy and early childhood are very rare, 
but cases have been reported. They may be non-inflammatory or in- 
flammatory, the distinction behveen the two often being very difficult to 



788 



PEDIATRICS. 



make. They may occur as a result of hemorrhage into the tissues of the 
stomach. 

They may be of follicular or tubercular origin, and the round perfo- 
rating ulcer has also been found. 

There are no diagnostic symptoms, but when vomiting of blood occurs 
ulceration may be suspected. 

The prognosis is bad. The treatment is necessarily symptomatic. 

Fig. 163 represents the stomach of a female infant one year old under 
the care of Dr. Northrup. 

Fig. 163. 




Follicular ulceration of stomach. Female, 1 year old. 



The infant was under treatment for one month. It had vomiting and diarrhoea. 
During the first week that it was in the hospital its temperature varied from 38.8° to 
39.4° C. (102° to 103° F.), after that being normal or subnormal. The respirations 
varied from 40 to 50, and the pulse from 120 to 140. In the second week it began to 
refuse its food and to emaciate. The diarrhoea continued and the vomiting was per- 
sistent. The vomitus was somewhat brownish in color, and the child died of exhaustion. 

On examining the stomach it was found that the lining mucous membrane was 
covered with small ulcers, varying in size from dots to 1 cm. (f of an inch) in diameter. 
The lesions appeared to be follicular ulcerations. In the middle of the specimen was a 
much larger ulcer which perforated the posterior wall. There was no evidence of an 



DISEASES OF THE STOMACH. 789 

inflammatory condition, and the cause of these lesions was unknown. There was, how- 
ever, a certain degree of necrosis around the ulceration. 

NEW GROWTHS. 

Morbid growths in the stomachs of infants and young children are so 
extremely rare that their occurrence need merely be referred to. 

B. Inflammatory.— The inflammatory lesions of the stomach may be 
either acute or chronic, and are termed gastritis. 

ACUTE GASTRITIS. 

Acute gastritis may be divided into (1) gastritis catarrhalis, (2) gastritis 
corrosiva, and (3) gastritis pseudo-membranosa. The cases in which or- 
ganic lesions of the stomach can be proved to exist are very limited in 
comparison with those in which the functional disorders are present. In 
a large number of cases which are spoken of as gastritis catarrhalis no 
catarrhal condition is present, and they would be much better classified 
under the heading of indigestion. Cases are numerous in which a diag- 
nosis of gastritis has been made during life and in which at autopsy no 
definite lesion has been found. When, however, gastritis is present, as a 
rule the acute form is more common in infants, while the chronic form 
occurs more frequently in children towards the age of puberty. 

Gastritis Catarrhalis Acuta (Acute Gastric Catarrh). — The cause 
of acute gastric catarrh is somewhat obscure, but it is usually supposed to 
arise from an exaggerated form of indigestion, or from the presence of 
irritants of various kinds. Infection may also be a cause, especially in 
the membranous form. 

Pathology. — The pathological lesions which characterize acute gastric 
catarrh are hyperaemia of the mucous membrane, hypersecretion of mucus, 
small punctate hemorrhages, and slight thickening of the mucous coat. 
In certain cases the inflammation has been found especially to affect the 
follicles. According to Booker, when a catarrhal condition of the gastric 
mucous membrane is present, the milk remains much longer in the stom- 
ach than under normal conditions, possibly four or five hours, or even 
more. A microscopic examination of the gastric contents in these cases 
shows various micro-organisms, and sometimes epithelioid and pus cells. 
The small number of bacteria found in cover-slip preparations from the 
contents of the stomach affords a most striking contrast to the large num- 
ber of bacteria which under like circumstances are found in the faeces. 

Two forms of acute gastric catarrh are usually described, the division 
being made according to the severity of the disease into subacute and acute. 

Symptoms, Subacute. — In the subacute form there is little or no fever, 
while in the acute the temperature is high. The subacute form is by far 
the more common. It is difficult and almost impossible to state definitely 
the symptoms of this form of gastric catarrh, as they so nearly approach 
to those which occur in cases of indigestion in which we believe no gross 



790 PEDIATRICS 

pathological conditions exist, that we should always be guarded in our 
use of the word catarrh. Pain is so common a symptom in all gastric 
disturbances, the existence of tenderness is so difficult to determine in 
infants and young children, and a hypersecretion of mucus is so often 
known to occur without the presence of an inflammatory condition, that 
there does not seem to be any one symptom on which we can rely. A 
general picture of the disease which is supposed to represent this form of 
gastric catarrh is that of slight fever, nausea, vomiting of food mixed 
with mucus, and at times of mucus alone, with a sense of tenderness, 
uneasiness, and discomfort in the epigastrium. There may be frontal head- 
ache, a rather swollen, coated tongue of somewhat glossy appearance, and 
often a slight follicular pharyngitis. There is loss of appetite, with at 
times hiccough and eructations of gas. The bowels are usually consti- 
pated at first, but after three or four days diarrhoea may be present. 
When an infant or child seems prostrated for a few days, and sick beyond 
what would be expected in an acute attack of indigestion, and when in 
combination with a slightly heightened temperature there is frequent vom- 
iting of mucus, we are justified in supposing that we are dealing with a 
subacute gastric catarrh. 

Symptoms, Acute. — Acute gastric catarrh is rare, but is a much more 
serious disease than the subacute form. It is characterized by high fever, 
39.4°, 40°, 40.5° C. (103°, 104°, 105° F.). The invasion is sudden. 
The disease may last for two or three Aveeks and show severe and alarm- 
ing symptoms. There may be active vomiting, delirium, and sopor in 
the beginning, so that it may be impossible to determine whether or not 
one of the other acute febrile diseases is developing. The characteristic 
symptoms of gastric catarrh develop later, and then the differential diag- 
nosis is easily made. 

Instead of the cessation of the vomiting in the first twenty-four or 
forty-eight hours, as in scarlet fever, and of the continuance of the cere- 
bral symptoms, as in meningitis, or of the development of pulmonary 
symptoms, as in pneumonia, the vomiting continues, though not quite so 
frequently as in the beginning, the mind becomes clear, and the symptoms 
point to the abdomen rather than to the head or thorax. The onset of 
pneumonia in some cases, though in my experience rarely, simulates this 
disease. The pulse is rather irregular. There ' is usually constipation at 
first, followed by diarrhoea later. 

Prognosis of Subacute and Acute Gastric Catarrh. — The prognosis 
in both these forms of catarrh is good except in very debilitated children. 
Treatment. — The treatment of cases of subacute and acute gastric 
catarrh is the same as that described in speaking of indigestion. Food 
should be withheld from the stomach for many hours, for it remains so 
long in the stomach that a fresh supply at short intervals will act as an ad- 
ditional source of irritation. In those cases which do not respond readily 
to long intervals of rest and to feeding with small quantities of a modified 



DISEASES OF THE STOMACH, 791 

alkaline milk, lavage will prove of value. Much judgment should he used 
as to the time when the food is to be increased in strength, for unless great 
precautions are taken relapses will frequently occur, and as a result the 
disease may finally become chronic. After convalescence has been estab- 
lished the child will begin to gain in weight. Some simple tonic, such as 
mix vomica, is usually indicated for a week or ten days until the child has 
recovered its strength. During the beginning of the attack, when food is 
being withheld, if the child is made very restless by extreme thirst, tea- 
spoonful doses of iced soda-water can be given, but with caution and as 
seldom as possible. After the irritation has been somewhat allayed, 
it is found valuable in certain cases to give dilute solutions of brandy, 
barley water, or white of egg in the form of albumin water before begin- 
ning with the treatment just spoken of. Albumin water is best made by 
dissolving the white of an egg 20 to 30 c.c. (f to 1 ounce) in water 120 
c.c. (4 ounces), and heating to 40° C. (104° F.). In this way the albu- 
min is held in solution, and the albumin water can be put on ice until 
needed for use. In especially intractable cases nothing should be put in 
the stomach for some time, nutriment being given in the form of pep- 
tonized milk with enemata. 

In the acute form, besides the treatment just mentioned, the child 
should be placed in a darkened room, soothing applications applied to the 
abdomen, and small quantities of iced soda-water given. If there is much 
exhaustion, stimulants are indicated. 

Gastritis Corrosiva Acuta. — Corrosive lesions of the mucous mem- 
brane of the stomach are at times produced by swallowing irritants, such 
as arsenic, carbolic acid, and caustic fluids. In these cases the lesions are 
usually found on the summits of the rugae. 

Treatment. — The treatment is by washing out the stomach with large 
quantities of water, administering the proper antidote, and feeding the 
child on a liquid diet so modified as to be as little irritating as possible to 
the injured mucous membrane. 

Gastritis Pseudo-membranosa. — The membranous form of gastritis 
is extremely rare in infancy and childhood. Cases have been reported, 
notably those of Wollstein. In these cases the congestion of the rugae was 
very marked, and along the greater curvature extended over an area of a 
number of inches. There was a thick grayish-green membrane, with some 
erosions. The gastric walls were much thickened. 

Symptoms. — The symptoms of gastric disturbance in these cases are often 
almost entirely absent, but there may be vomiting, pain, and tenderness 
in the epigastric region, and insatiable thirst. A pathognomonic symptom 
would be the vomiting of shreds of membrane, with or without an admixture 
of blood. This symptom is, however, extremely rare, because the mem- 
brane is usually adherent, so that a differential diagnosis is often impossible. 

Prognosis. — The prognosis is very unfavorable. 

Treatment. — The treatment is purely symptomatic. 



792 PEDIATRICS. 

CHRONIC GASTRITIS. 

Chronic gastritis is not usually met with in infancy, but occurs in later 
childhood, and is then in form catarrhal. It is especially common in the 
summer months, and is generally the result of neglect or of improper 
treatment of the acute form of the disease. 

Gastritis Catarrhalis Chronica (chroyiic gastric catarrh). — Pathol- 
ogy. — The pathological condition which is found in chronic gastric ca- 
tarrh is the result of long-continued hyperemia. There is often a slaty 
discoloration of the mucous membrane, with cellular infiltration of the 
submucosa. In addition to this there is usually found a considerable 
quantity of tough mucus. 

Symptoms. — The symptoms are not so clearly defined as in the acute 
form of the disease, but are variable and of a rather sluggish type. The 
tongue is apt to be much coated and the breath to have a disagreeable 
odor. There is considerable abdominal distention after meals, so that the 
children complain that their clothes feel uncomfortable. 

Frontal headache is apt to occur. The children gradually grow thin 
and anaemic. They vomit at irregular intervals, and are usually consti- 
pated. There is often a slight cough, and the symptoms, so far as the 
stomach is concerned, may form so small a part of the general picture of 
the disease that the child is not infrequently brought to the physician on 
account of its cough and because it is supposed to have some pulmonary 
affection. 

Prognosis. — Although the disease is often somewhat intractable, the 
prognosis under proper treatment is good. It may last for three or four 
months ; but in many cases which are usually considered chronic gastric 
catarrh it has seemed to me there is no organic lesion, but that the disease 
is functional in its character, and the prognosis consequently very good. 

Treatment. — It is often necessary in these cases to precede the treat- 
ment by carefully washing out the stomach. We must remember, how- 
ever, that a considerable quantity of mucus may be in the stomach, which 
cannot be removed by washing, so that if the symptoms continue after 
one or two washings, even though no mucus is returned by the tube, we 
should repeat this treatment from time to time. The diet should be an 
alkaline modified milk, with a low percentage of proteids, if necessary 
peptonized, and a moderate percentage of fat and sugar. The percentages 
of the different elements should be increased as improvement in the gastric 
symptoms takes place, and later broths and milk can be tried. Symp- 
tomatically in certain cases pepsin, dilute hydrochloric acid, and bismuth 
are occasionally indicated. A valuable tonic in the after-treatment of 
these cases is nux vomica. 



DISEASES OF THE INTESTINE. 793 



DISEASES OF THE INTESTINE. 

GENERAL CONSIDERATIONS.— Diarrhoea.— As vomiting is the 
most significant symptom of gastric disturbance, so diarrhoea resulting 
from increased intestinal peristalsis is the most characteristic symptom of 
intestinal disturbance. Diarrhoea is always a symptom, never a disease. 
There seems to be a predisposition to diarrhcea in the first two years of 
life, w T hich decidedly lessens as the child grows older. The most fre- 
quent time for the occurrence of diarrhcea is during the summer months. 

Prophylaxis. — Much can be done at all seasons of the year to pre- 
vent the occurrence of diarrhoea, but prophylaxis is of the utmost im- 
portance in warm weather. The children should be protected by proper 
clothing from extremes of heat and cold, and from dampness. They 
should, if possible, be taken away from crowded or unclean districts in 
cities and towns during the hot weather, and have the advantages of fresh 
country or sea air and good hygienic surroundings. Both the quality and 
the quantity of the food should be carefully regulated, care being taken 
not to give too much food, as the depression due to heat weakens the 
digestive function. In very hot weather an extra amount of water should 
be allowed and the solid food somewhat diminished in amount. As milk 
is the most common source of infection in the diarrhceal diseases, and as 
bacteria multiply more rapidly as the weather becomes warmer, it is espe- 
cially important to have the milk fresh and sterile during the summer 
months. It must be understood that not only bacteria but also their 
toxines, which are not destroyed by pasteurization or sterilization, may 
produce most serious results. Uncooked fruits and food are contra-indi- 
cated in very hot weather. Especial attention should be paid to any slight 
indisposition which may arise in hot weather, as it may render the child 
more vulnerable to the various causes of diarrhcea. 

Intestinal Contents. — The intestinal contents should be studied in 
regard to their color, consistency, composition, odor, and amount. The 
changes which take place in the intestinal contents are significant of dis- 
eased conditions, but not necessarily of any especial disease. 

Color. — The color of the faecal discharges varies greatly, and it would 
be impossible to describe completely all the variations from the normal 
when there is disturbance of the intestinal contents. A number of the 
abnormal colors more usually seen are shown in Plate III., facing page 84. 

The square numbered 16 is what is usually spoken of as clay-colored. 
This clay color may be due to a diminution in the amount of bile which 
enters the intestine, or to undigested fat. This color is abnormal, and is 
usually met with in intestinal diseases of a subacute or chronic type. It 
does not necessarily indicate a serious condition, however, as even a small 
plug of mucus may interfere with the flow of bile into the duodenum. 

Number 17 may be simply a change that has taken place after the 



794 PEDIATRICS. 

faeces have been passed, and which often is not significant of any especial 
pathological condition. It may, however, show that the changes which 
have taken place in the food during its passage through the intestine have 
not been entirely normal. It is the least important of the changes 
which take place in the color of the intestinal contents. The colors in 18 
and 19, are what may be seen in a more serious disturbance of the en- 
teric tract. These colors may appear in any of the intestinal diseases 
which are accompanied by diarrhoea, but are significant of no especial 
disease. They are merely to be considered pathological in contradistinc- 
tion to the normal colors seen in 3, 4, 6, 7, 8, 9, and the beginning ab- 
normal condition represented in 17. 

Besides these shades of green there are a great many varieties of color 
produced by the mixture of green, yellow, white, and brown. These are 
valuable merely as instructing us whether we are dealing with a normal 
or an abnormal condition of the intestinal contents, and are not sig- 
nificant of any one disease, either functional or organic. Much variety in 
the color also arises from the admixture of blood, mucus, and shreds of 
membrane. In this connection it is well to remember that the yellowish- 
white lumps seen in undigested faeces are often made up of fat as well as 
of proteid material. 

The color of the intestinal contents may also be changed by the ad- 
ministration of various drugs, such as iron, which causes a more or less 
black color. Bismuth gives the colors which are seen in 12, 13, and 14. 
Number 12 is the color which was produced by giving to an infant 0.18 
gramme (3 grains) of bismuth every two hours for six doses ; number 13, 
when 0.24 gramme (4 grains) of bismuth was given every two hours for 
six doses ; and number 14, when the latter dose had been omitted for 
twenty-four hours. The size of the dose and the intervals between its 
administration will of course produce different shades of color. 

When the solids of the intestinal contents are much reduced in pro- 
portion to the serum, as in cases of acute and frequent diarrhoea, the dis- 
charges become more and more fluid, and sometimes almost entirely lose 
their color and look like water. 

Consistency. — In the first year of life, or while the infant is having 
only milk for its food, the consistency of the faecal discharges is inter- 
mediate between solid and fluid, and the discharge, as a rule, is smooth 
and free from lumps. As the infant begins to take other forms of food 
and a mixed diet, the faecal discharges gradually become more solid. 
The consistency of the faecal discharge is abnormal when it becomes 
liquid, as in diarrhoea, or when it is too solid, as in constipation. 

Composition. — In addition to the various substances which make up 
the food which enters the intestine, the faecal discharges contain bile, 
mucus, epithelial remains, and many bacteria. In diseased conditions 
they may also contain certain morbid elements, such as blood, pus, and 
membrane. In intestinal diseases of both an acute and a chronic type the 



DISEASES OF THE INTESTINE. 795 

mucus may be very largely increased, but it cannot be considered to be 
especially characteristic of an inflammatory condition, as the secretion of 
mucus apparently may be very much increased in purely functional con- 
ditions. The bacteria are very numerous and of many varieties, but in 
most cases the detection of any especial form of these organisms does not 
aid us in diagnosticating the especial disease. Notable exceptions to this 
statement are where one finds the typhoid bacillus, the comma bacillus, 
and the amoeba coli. 

Odor. — While in the normal faecal discharges of infants fed entirely 
on milk the odor is comparatively slight, it becomes much stronger as 
other articles of food, either of a starchy or of a proteicl nature, are added 
to it. When an abnormal condition exists, various changes take place, as 
in acid fermentation, in which the odor is supposed to be sour, and in 
albuminous decomposition, in which the odor is supposed to be very foul, 
but these distinctions cannot with our present knowledge be said to be 
definitely proved. Although these can scarcely as yet be considered of 
great diagnostic importance, they are sufficiently so for us to make use of 
them in the diagnosis and treatment of intestinal diseases. Thus, when 
acid fermentation is supposed to be present, a reduction in the percentage 
of the sugar is indicated, while when albuminous decomposition is sus- 
pected a reduction of the proteids in the food is called for. 

Amount. — In estimating the amount of the faecal discharges we must 
consider the total amount in twenty-four hours, and not the large or small 
amount which may occur at one movement. The total amount in twenty- 
four hours is of much importance in both the acute and the chronic dis- 
eases of the intestine. In the acute diseases, the more frequent the diar- 
rhoea and the larger the amount the greater is the exhaustion and the 
worse is the prognosis. In some chronic diseases the total amount of 
faecal discharges may be very large. In these cases the larger the total 
amount the less has been the absorption and the worse is the prognosis, 
for this condition is an indication that the child is being starved from a 
lack of power to absorb the food which has been given to it. 

Diseases of the intestine may be divided into three classes, — develop- 
mental functional, and organic. 

I. DEVELOPMENTAL. — Certain malformations and malpositions of 
the intestines occur as a result of abnormal development. The malfor- 
mations have already been considered under diseases of the new-born. 
Malpositions are met with in infants when there is a transposition of 
the abdominal organs, or when portions of the intestines are found to be 
outside of the abdominal cavity. 

II. FUNCTIONAL. — The functional diseases of the intestine may be 
classed as acute, chronic, and eliminative. The acute functional diseases 
of the intestine may arise from nervous disturbance or from indigestion, 
which is sometimes more marked in the duodenum, and sometimes in 
the intestine beyond the duodenum. 



796 PEDIATRICS. 

ACUTE NERVOUS. 

In certain infants and children whose nervous system is easily affected 
exaggerated peristalsis causing diarrhoea may arise from a number of 
causes without any known lesions, fever, or gastric disease. Among these 
causes may be cited heat, cold, and fright. In like manner in these indi- 
viduals foreign bodies, food or otherwise, may by simple reflex irritation 
cause such a nervous disturbance as to produce diarrhoea. In these cases 
either the small or the large intestine, or both, may be affected, and, so 
far as we know, the mucous membrane is either normal or simply hyper- 
aemic. There is more or less serous exudation. These cases are rare in 
comparison with the other forms of diarrhoea, such as those which are 
caused by bacteria, and in them intestinal decomposition and intestinal 
inflammation are not present primarily. 

Symptoms. — The symptoms of simple diarrhoea are very apt to appear 
suddenly. There is usually abdominal pain, not, as a rule, of great in- 
tensity. At first there are two or three rather liquid yellowish-brown dis- 
charges occurring at intervals of perhaps one-half or one hour, and often 
accompanied by considerable flatus. There is a certain amount of rest- 
lessness, pallor, and exhaustion. Vomiting is rarely excessive. The tem- 
perature, as a rule, is not raised, or is raised very slightly. The pulse is 
rather weak and somewhat accelerated. The number of the discharges 
may be eight, ten, or twelve in the twenty-four hours, and these soon 
become watery and of a lighter color, but are seldom green. The odor 
is somewhat increased, but not excessively. These symptoms, unless 
they are exaggerated by improper food or by bad treatment, usually dis.- 
appear in a few days. 

Treatment. — The treatment is essentially to remove the cause. If the 
cause is atmospheric, a change in climate is sometimes necessary. If un- 
digested food is causing intestinal irritation, a dose of castor oil, 3.75-7.50 
(drachms 1 to 2), or calomel, .006 gramme ( r V grain), every hour for ten 
doses, may be given, but, as a rule, this is not necessary. The child 
should be kept in bed. Food should be withheld for some hours. 
After the cause has been removed, the treatment should be to control the 
peristalsis and the pain. For this purpose a few drops of tinctura opii 
camphorata and hot applications to the abdomen are indicated. If there 
is a tendency for the diarrhoea to continue, the subnitrate of bismuth may 
be given, and in some cases when there are signs of exhaustion a stimu- 
lant may be needed. In the cases in which the excessive peristalsis seems 
to be prolonged by weakness, brandy in small doses is more useful than 
astringents or opium. For several days the diet should be simply milk 
heated for twenty minutes at 75° C. (167° F.), and containing ten per 
cent, of lime-water. These simple diarrhoeas, especially in hot weather, 
should never be allowed to continue, as they render the intestine vulner- 
able to the more serious diseases caused by micro-organisms, which may 
at any moment gain an entrance in this way. 



DISEASES OF THE INTESTINE. 797 

ACUTE INDIGESTION. 

Disturbances arising from intestinal indigestion, although in most cases 
having their origin in the duodenum, seem also in quite a number of 
cases to be located in the intestine beyond the duodenum. It has yet to 
be proved that any pathological lesion is present in these cases, and for 
the present they must be looked upon as functional. 

These cases vary in their symptoms with the individual and according 
to the part of the intestine which is most involved. In one set of cases 
where the irritation is probably below the duodenum, the disturbance of 
digestion is shown simply by the increased peristalsis, such as has been 
described in the nervous cases, but here the evidence points to an undi- 
gested condition of improper articles of food which have been given and 
which appear in the discharges. The treatment of this class of cases is 
very simple, and consists in first giving a laxative and then regulating 
the diet according to the age of the individual. 

Symptoms. — What is usually spoken of as a 4k bilious attack" represents 
another class of cases. This condition is very rare in infancy, and usu- 
ally occurs in middle and later childhood. In these cases, in addition to 
the increased peristalsis and evidence of undigested food, there are fre- 
quently icterus and vomiting of bile, indicating that there is irritation in 
the duodenum. In addition to these symptoms there may be headache 
and excessive nausea. The icterus is usually slight in degree, but often is 
marked and is noticeable in the conjunctivae and in the urine. Plate III. 
(facing page 84), No. 11, shows the staining of bile on the napkin from 
the urine of an infant during an acute attack of indigestion involving the 
duodenum and accompanied by icterus. The temperature in these cases 
is usually slightly raised for a few days and then becomes subnormal. In 
a certain number of cases the faecal discharges become clay-colored. This 
color is often produced mechanically, as has already been explained. 

Prognosis. — Although the symptoms in these acute attacks may often 
appear quite serious, the prognosis is always good. In some individuals 
they are liable to recur even when the diet and the general health are well 
attended to. 

Treatment. — In the treatment of this class of duodenal disturbances 
we must consider that the fats in the food are in all probability especially 
liable to prolong the disease by not being properly digested so long as the 
function of the duodenum is involved. We should, therefore, in treating 
these cases, lessen the amount of fat given in the food. I have found 
that the treatment which most speedily shortens the attack is (1) total 
restriction from food for twelve hours, with the administration of small 
quantities of cold, sterilized water if the thirst is excessive, and (2) the 
administration oj' small quantities of milk modified as in the following 
prescription : 



798 PEDIATRICS. 

Prescription 86. 

Pat ... 0. 16 

Sugar 6.00 

Proteids 3, 00 

Lime-water 10. 00 

The mixture to be heated to 75° C. (167° F.) for twenty minutes ; from 
120 to 180 c.c. (from 4 to 6 ounces), according to the age, to be given 
every three hours. In some cases also the diet of proteids may be varied 
by giving expressed beef-juice or solutions of white of egg. 

Under this treatment the icterus usually passes away in a few days, and 
the child can then soon be given its ordinary food. 

CHRONIC. — The chronic functional diseases of the intestine may be 
the result of acute nervous disturbances, or they may arise from a num- 
ber of prolonged attacks of acute indigestion. They may be divided into 
(a) nervous, (b) tubular, (c) duodenal indigestion, (d) intestinal indigestion, 
(e) incontinence, (/) constipation. 

CHRONIC NERVOUS. 

In the chronic form of nervous functional intestinal disturbance either 
the small or the large intestine may be affected, and the condition of the 
mucous membrane, so far as we know, is either normal or hyperaemic. 
The causes are the same as in the acute form. This class of cases is not 
especially common, as they are merely a prolongation of the symptoms 
which I have already sufficiently described in speaking of the acute cases. 
The treatment of these cases is essentially with stimulants and care of the 
general health. 

TUBULAR. 

In addition to these more common intestinal affections of nervous 
origin is one that is called tubular. This disease is so rare before the age 
of puberty that it need only be alluded to. It is a condition of the 
mucous membrane of any part of the intestine in which an exudation of 
mucus takes place in such a way that masses closely simulating a mem- 
brane may occur on the surface. When discharged through the rectum 
they are sometimes found to have formed a cast of the intestine. These 
masses are mostly made up of mucus, and may occur in shreds of greater 
or less extent, as well as in the tubular form. The disease is supposed 
to be of nervous origin. 

Symptoms. — The symptoms are pain, tenderness, and tenesmus. The 
temperature is usually normal. 

Prognosis. — The prognosis, as a rule, is good, although in some cases 
the disease may be much prolonged. 

Treatment. — The treatment is to be directed towards.the improvement 
of the general health and the nervous condition, the local treatment being 
simply symptomatic. 



DISEASES OF THE INTESTINE. 799 



CHRONIC DUODENAL INDIGESTION. 

The chronic form of functional intestinal indigestion plays an important 
part in intestinal disease, especially when it is located in the duodenum. 
Chronic indigestion of the duodenum constitutes a disease of itself, and is 
one of the most difficult to cure. It has usually been spoken of under 
the names of chronic gastritis, duodenal catarrh, and mucous disease. 
We at present, however, have no proof that catarrhal or any other 
pathological lesions of the mucous membrane are present in these cases, 
and the weight of evidence is in favor of the view that the disease is 
purely functional. 

Etiology. — The etiology of chronic duodenal indigestion is in many 
cases obscure, but in a large number of cases it is produced by the con- 
tinued administration of food which is not adapted to the age or digestive 
capacity of the child. It is at times met with as a sequela of some ex- 
hausting disease, such as typhoid fever, pneumonia, pertussis, or one of 
the acute exanthemata. It very rarely occurs in early infancy, being com- 
monly met with during the middle and later periods of childhood. 

Symptoms. — The symptoms are at first somewhat varied. The disease 
may be preceded by a number of attacks of gastro-enteric indigestion of a 
subacute character. A tendency to nausea and vomiting extending over 
a number of months may sometimes precede the full development of the 
disease. The gastric disturbance, however, is not marked, and is proba- 
bly a reflex condition depending upon the functional disturbance of the 
duodenum. At first the faecal discharges show merely the various changes 
which occur in ordinary indigestion, sometimes manifesting a tendency to 
diarrhoea and sometimes to constipation. The color of the discharges at 
this early period is not significant of anything beyond ordinary indigestion, 
and is usually a mixture of yellow, white, and green. As the disease 
progresses, certain characteristic symptoms arise and definitely mark its 
presence. Mucus begins to appear in the faecal discharges, and soon be- 
comes quite large in amount. It may occur in shreds or masses of con- 
siderable size, and is sometimes found covering hard lumps of faeces. 

With this hypersecretion of mucus, which is not necessarily an indi- 
cation of an inflammatory condition, the child begins to be fretful, to be 
wakeful at night, to grind its teeth, and to lose in weight. The skin be- 
comes dry, and there is usually a coexisting follicular pharyngitis which 
causes a short, dry cough. The child gets tired easily, and complains of 
pain in the epigastrium after eating. The abdomen is apt to be distended 
and tympanitic. There are frequently frontal headache, a coated tongue, 
and a disagreeable odor to the breath. The faecal movements now begin 
to become clay-colored, and the skin to assume a sallow tint, with at times 
a slight amount of icterus. Sometimes an exacerbation of all the symp- 
toms takes place, resulting in an acute attack of indigestion. These 
symptoms, varying in intensity, and sometimes ceasing to be prominent 



800 PEDIATRICS. 

for days or weeks, usually continue for months, and in intractable cases 
may last for years. The temperature in this disease is usually normal, 
sometimes subnormal, but may of course, where an exacerbation occurs, 
be somewhat raised. The pulse is usually moderately slow. Sometimes 
a subacute form of bronchial catarrh accompanies the disease, but it does 
not appear to be a part of it. The appetite varies, is often unnaturally 
great, and there is sometimes a craving for large quantities of sugar. 

Diagnosis. — When all the symptoms are present, the diagnosis of 
chronic duodenal indigestion is not difficult. The appearance of the child 
is characteristic. Its eyes are dull and heavy ; its skin is dry and harsh 
and sometimes slightly icteric, while the loss of flesh, the distended and 
tympanitic abdomen, and the coated tongue are more marked than in any 
other disease. When, in addition to this picture, an examination of the 
faecal discharges shows them to be clay-colored and to contain a large 
amount of mucus, the diagnosis is quite evident. The disease which is 
most commonly mistaken for chronic duodenal indigestion is pulmonary 
tuberculosis. The short, dry cough, the emaciation, and in some cases 
the bronchial catarrh, often make parents and physician fear that this 
serious disease is present. If, however, the entire history of the case is 
studied carefully, pulmonary tuberculosis can soon be eliminated. 

Prognosis. — The prognosis of chronic duodenal indigestion is in most 
cases good. Even in those cases which last for a period of years the 
health is usually entirely restored. When, however, the disease has 
lasted for a long time, and the child is in a very debilitated condition, the 
prognosis becomes more serious. 

Treatment. — The treatment of this disease is essentially by diet, and 
not by drugs. Such articles of food should be given as will be chiefly 
digested by the stomach and will not tax the duodenal digestion. This of 
course indicates a proteid diet, and contra-indicates the administration of 
starches, sugars, and fats. In order not to tax the disturbed duodenum 
by overloading it in its weak condition, small amounts of food at shorter 
intervals than usual are found to produce a better result than the regular 
three or four daily meals. The diet which I have found most valuable in 
treating these cases is a milk so modified as to have a low percentage of 
sugar and fat, a high percentage of proteids, and ten or fifteen per cent, 
of lime-water. Soups of various kinds, and meat, can also be given, and 
the crust of bread in limited quantity. A valuable adjuvant to this treat- 
ment, as a mild astringent and stimulant, is a small amount of claret, 
preferably given in seltzer water. The meals should be five in the twenty- 
four hours. It is exceedingly difficult in most cases to keep the child on 
this diet, but if it is rigorously enforced the duration of the disease will be 
decidedly shortened. As the epigastric pain and the amount of mucus 
in the discharges grow less, the diet may be somewhat varied by giving 
fish and eggs, and the percentage of lime-water in the milk may be re- 
duced to five. As relapses occur very easily, however, it is generally best 



DISEASES OF THE INTESTINE. 801 

to continue with this rigid diet until the faecal discharges have become 
normal in color and have not shown the presence of mucus for a number 
of weeks. In mild cases when there is much constipation, small doses 
of calomel, or any mild laxative, are indicated. Podophyllin can also be 
given, as in this prescription (Prescription 87) : 

Prescription 87. 
yietric. Apothecary. 

Grammes. 

R Podophyllin 0J06 R Podophyllin gr. i ; 

Alcohol 3| 75 Alcohol 3 i. 

M. M. 

Sig. — Prom 3 to 5 drops, according to the age of the child, in the morning and even- 
ing, lessening the dose if it causes more than two discharges daily. 

When there is a tendency to diarrhoea, small doses of bismuth are 
found to be valuable. 

Tincture of nux vomica freely diluted in water and given in doses of 
a few drops after each meal seems in some cases to be of value. 

The remainder of the treatment is essentially symptomatic, and if the 
children are weak and anaemic tartrate of iron and potassium can be given. 

During the whole course of this disease cod-liver oil is contra-indicated, 
but when the disease has been cured and the child is left weak and emaci- 
ated it may in some cases be beneficial. Its administration, however, 
should always be carefully supervised, as it may cause a relapse. The 
specially restricted diet should be continued for some time after the charac- 
teristic symptoms of the disease have disappeared, or relapses will occur. 

The following case is illustrative of chronic indigestion of the duodenum. A girl 
six years old and healthy at birth, was nursed until she was thirteen months old. 
During her first year she had an attack of bronchitis. Previous to this attack she had 
never had any intestinal disturbance. Her abdomen was always rather prominent. 
From her earliest infancy she had been a nervous child, had not slept well, had talked 
much in her sleep, and had occasionally walked in her sleep. During the first six 
months of the disease the symptoms were chiefly loss in weight and cough. She then 
had an attack characterized by vomiting for twenty-four hours, followed by anorexia, 
fever, languor, and apathy ; the bowels became constipated the skin icteric, the urine 
dark-colored, and the faecal movements light-colored. She had an intense craving for 
sugar, and ate all that she could lay her hands on, so that she had to be watched very 
closely to prevent her satisfying this morbid appetite. Her appetite for other articles 
of food was poor. The abdomen was distended and tympanitic, and the tongue 
coated. The breath had a disagreeable odor, and there was loss of flesh. There was 
a follicular pharyngitis, which evidently caused the cough. 

The child was placed on the following diet. Her first meal was milk so modified 
as to contain fat 2, sugar 3, proteids 4. lime-water 10. With this meal she was 
allowed to have a small amount of the crust of French bread. The second meal con- 
sisted of broth and the crust of French bread, and one ounce of claret in half a tum- 
bler of seltzer water. The third meal consisted of meat, the crust of French bread, 
claret, and seltzer water ; the fourth, of soup, the crust of French bread, claret, and 
seltzer water ■ the fifth of the modified milk and the crust of French bread. After 
each meal three drops of tincture of nux vomica were administered. 

51 



802 PEDIATRICS. 

This diet was carried out rigorously for one week. At the end of that time the 
child looked much better, the urine was clear, the faecal movements began to resume 
a more natural color, the mucus in the discharges was very much lessened, and the 
abdomen was not so much distended. The tongue was less coated, and the cough 
had almost disappeared. It was also found that the craving for sugar had much de- 
creased. The diet was then slightly increased in variety. At the end of a month the 
child had recovered entirely, and some weeks later an ordinary diet at the usual times 
was given to her. 

CHRONIC INTESTINAL INDIGESTION. 

There is a class of cases in which the disturbance seems to be located 
in the intestine beyond the duodenum and to be comparatively free from 
gastric symptoms. These cases are characterized by their chronic course, 
by the irregular character of the intestinal discharges, which at times 
are normal, and by presenting when abnormal most varied appearances. 

Symptoms. — As a rule, these infants do not gain regularly or normally. 
They become anaemic. The skin may be dry. They are fretful, do not 
sleep well, and in fact present the usual signs of malnutrition. 

Treatment. — The treatment is to study carefully each case and feed it 
according to its especial idiosyncrasy. No especial drugs are indicated. 

INCONTINENCE OF FiECES. 

Incontinence of faeces is a condition in which the faecal movements 
occur involuntarily. This may be due to inability to control the sphincter 
ani, or to loss of power of the sphincter itself. The first class of cases, 
due to disease or injury of the spinal cord, or to absence of reflex sen- 
sation, is rare. The second class is due to an atonic condition of the 
sphincter. The treatment of the first class of cases is essentially that of 
the disease in which it occurs. The treatment of the second class is 
illustrated in the following cases : 

A boy, eleven years old, much overworked at school, had been made to study a 
number of languages, and allowed to take only a very limited amount of exercise in the 
open air. He completely lost control of the sphincter ani, and became very anaemic 
and weak. Nothing abnormal was found on a physical examination. The boy was 
taken from school, relieved entirely of his studies, and kept in the open air most of 
the day. Under this treatment, in addition to the administration of tartrate of iron 
and potassium and claret, he improved rapidly, and in two months was entirely well. 

Another boy, seven years old, came to the Children's Hospital, with a history of 
incontinence of faeces lasting over a year. He illustrated the condition of incontinence 
from habitual constipation, as the incontinence was found to depend on the stretching 
of the rectum by impacted faeces. The rectum was emptied by a dose of castor oil and 
an enema each day. At the end of a week the boy had ceased to have involuntary 
faecal movements, and has since continued well. 



CONSTIPATION. 

By constipation is meant a condition in which the movements of the 
bowels do not take place as often as is normal for the individual, and in 



DISEASES OF THE INTESTINE. 803 

which the consistency is abnormally increased. Constipation is a symp- 
tom and not a disease. It is a relative term, as what would be normal in 
one individual may be abnormal in another. During the first year of life 
two or three daily discharges may be considered normal, in the second 
year two discharges, and in the third and fourth years one discharge is the 
usual number. The causes of constipation are varied and, in many cases, 
rather obscure. They may be mechanical, but are usually functional, and 
either spasmodic or atonic. As the sigmoid flexure is proportionately 
long in infancy, flexions may occur with the result of producing a me- 
chanical obstruction. 

Spasmodic. — The spasmodic cases are rare, but should be recognized, 
as they frequently cause much disturbance of the child's general health. 
They are usually due to fissures about the anus or to an increased size 
and consistency of the faeces, which, by causing pain in defecation, result 
in spasmodic closure of the sphincter. 

Treatment. — The treatment of the spasmodic cases, when the cause 
is from fissure or, as in some instances, from hemorrhoids, is described 
on page 813. When an abnormal size or consistency of the faeces is pro- 
ducing the spasm, the rectum should be thoroughly emptied for a number 
of days by mechanical means. This may be in the form of enemata of 
equal parts of glycerin and water, or in extreme cases by using the finger, 
well oiled, to break up and draw out the pieces. The subsequent treat- 
ment would be the same as described below in the atonic cases. The 
size of the faecal masses may at times be enormous, and in these cases a 
mechanical dilatation of the rectum may result. Gradual dilatation of the 
sphincter with bougies two or three times a week has proved a valuable 
adjunct to the treatment of these more severe cases, the rectum gradually 
recovering its normal caliber. 

Atonic. — The atonic is the most common form of constipation, and 
simply represents a sluggish condition of the intestinal peristalsis. This 
may arise from weakness of the intestinal muscles. A weakened condi- 
tion may result from a child not being taught to have its bowels moved at 
regular times. The lack of exercise which is so common in the child's 
life during the winter months accounts for many cases in which during the 
summer months, when the child is out of doors playing all day, the bowels 
are no longer constipated. Any disease of a debilitating nature, as well 
as the indiscriminate use of laxative drugs may cause this weakness of 
the intestinal muscles. The most common of all the causes, however, is 
the food, which is insufficient in amount or improper in quality for the 
digestion of the especial child. In infants who are being fed exclusively 
on milk, a low percentage of fat in the milk seems in a number of cases 
to produce constipation. I have noticed, however, that when a breast- 
milk contains a low percentage of fat and a high percentage of proteids 
the faecal movements are thin and water)'. In some cases boiling, or 
even pasteurizing, the milk produces obstinate constipation, but in many 



804 PEDIATRICS. 

cases no such condition is produced. In young children a lack of the 
proper amount and combinations of vegetables, meats, and fruits is a very 
common cause of constipation. 

Symptoms. — In addition to the usual symptoms of infrequency of defe- 
cation, straining, and increased consistency of the faeces, there are others 
which are often overlooked. There may be general nervous symptoms, 
such as fretfulness, apathy, insomnia, and pain varying in its locality, 
sometimes being prominent in the head and sometimes in the abdomen. 
It is not uncommon to find streaks of blood with the fseces when the 
strain is excessive. 

Diagnosis. — The diagnosis of the condition of constipation is self-evi- 
dent; the difficulty arises in detecting the cause and locating the part of 
the intestine in which the atonic condition exists. When it is the rectum 
that is chiefly affected there are, as a rule, no especial symptoms which 
cannot be relieved by the use of enemata or suppositories ; when it is the 
upper part of the small intestines the symptoms connected with intestinal 
indigestion aid us in the diagnosis. 

Prognosis. — As a rule, constipation can be easily cured, but some 
cases are extremely intractable and last for a number of years. In the 
mechanical cases, as soon as the intestine has become more developed 
and assumed the relative proportions found in adult life, the constipation 
is very apt to pass away ; so in these cases we may give a favorable prog- 
nosis. 

Treatment. — The treatment of the atonic cases is to remove, when 
possible, the causes which have already been cited, and to give the proper 
treatment to the disease from which the constipation has resulted. Regu- 
lar habits as to the movement of the bowels, exercise, and meals are very 
important. 

Diet — Reliance should be placed on the regulation of the diet, rather 
than on drugs, which should, as a rule, be looked upon as of only tempo- 
rary use. When the infant is being fed on modified milk, we should re- 
member that a variation in the percentage of the sugar, as well as of the 
fat, may produce constipation in certain individuals. During the first year 
the percentages to be obtained as soon as possible are : 

Fat 4.00 

Sugar 7.00 

Proteids 2.00 to 3.00 

During the second year whole cow's milk, with the addition of cream, 
should be given. It is often advisable to reduce the amount of cereals 
and increase the amount and variety of vegetables and fruits. Of the 
latter, baked apples, orange-juice, stewed prunes, and ripe peaches are 
especially indicated. Broths and meat-juices should also be given, and as 
the child grows older, sometimes at two years, butter, and at two and a 
half years meat, should be added to the diet. Hot or cold water given 



DISEASES OF THE INTESTINE. 805 

before breakfast, either with or without orange-juice, is often efficacious. 
Massage of the abdomen in certain cases of obstinate constipation has been 
a most successful form of treatment. Suppositories of either gluten or 
glycerin are especially efficacious when the rectum is chiefly at fault. 
Enemata, either of soapsuds and water or equal parts of glycerin and 
water, are very useful in temporarily removing the symptoms until the 
more radical form of treatment by the regulation of the diet is thoroughly 
established. 

Drugs. — When drugs are indicated, purgatives and, as a rule, laxatives 
should be given but sparingly, and only with the idea of giving tempo- 
rary relief. In older children, cascara can be given, either in the form of 
the elixir, 3.75 to 7.50 c.c. (1 to 2 drachms), or the fluid extract, 0.18 to 
0.3 c.c. (3 to 5 minims). Nux vomica, according to the age of the child, is 
especially valuable in the form of the tincture, 0.12 to 0.24 c.c. (2 to 4 
minims). For young infants the milk of magnesia, 1.88 to 3.75 c.c. (J to 
1 drachm), or olive oil, 3.75 c.c. (1 drachm), or phosphate of soda, 0.12 c.c. 
(2 grains), should be given. All these drugs should be given in as small 
doses and as seldom as is sufficient to produce a satisfactory result, and 
should be omitted as soon as possible. 

ELIMINATTVE. 

Under the term eliminative disturbances of the intestine are included 
a number of unexplained and obscure symptoms which we at present are 
unable to classify elsewhere. It is probable that they will be more fully 
understood in the future. It seems as though the intestine often acts as 
an organ for the elimination of various morbid products from the econ- 
omy. The diarrhoea which results from the irritation of these foreign 
elements is not distinguishable from that which occurs when the irritation 
is primarily in the intestine itself. Our knowledge of this class of dis- 
turbances is, however, so small that I shall merely refer to its possible 
occurrence. 

III. ORGANIC. — The organic diseases of the intestine may be divided 
into non-inflammatory and inflammatory. 

A. Non-Inflammatory. — The non-inflammatory diseases of the intes- 
tine may be divided into fermented, mechanical, and new growths. 

ACUTE FERMENTAL.. 

The non-inflammatory conditions of the intestine, which for want of a 
better term we speak of at present as fermental, include those which arise 
from acid fermentation and albuminous decomposition, which are pro- 
duced by micro-organisms. The disturbances which arise from these 
causes represent the greater proportion of the diarrhceal diseases which 
occur during the warm months of the year. 

Etiology and Pathology. — The causes of fermental disturbance in the 
intestine lie in impure or improper foods and bad hygienic surroundings. 



806 PEDIATRICS. 

In both acid fermentation and albuminous decomposition it is probable 
that the small intestine is most affected. The condition of the mucous 
membrane may be normal, or there may be desquamative catarrh. The 
process may go no farther, or it may be followed by inflammatory changes 
in the intestinal mucous membrane. 

The fermental class of cases holds a position midway between the 
nervous forms of intestinal disturbance and the inflammatory forms with 
their pronounced lesions. (See Ileo-Colitis, page 820.) 

Symptoms. — The great variety of causes which give rise to these fer- 
mental processes result in a variety of symptoms. The onset may be 
subacute, with little or no fever and without vomiting, or it may be acute 
and accompanied by a high temperature and active vomiting. After a 
variable period of general discomfort and restlessness, diarrhoea sets in, 
which varies so greatly as to its frequency, amount, color, and consistency 
that it would be impossible in the present state of our knowledge to divide 
these variations clinically. The onset of fermental diarrhoea is, however, 
so often characterized by the toxic symptoms of sudden rise of tempera- 
ture, followed after a day or so by a normal temperature, that when we 
meet with this occurrence we are usually justified in eliminating the in- 
flammatory and more serious intestinal lesions. In some cases the diar- 
rhoea, although accompanied by much prostration and various nervous 
disturbances, disappears after a few days ; in others, especially in the 
warm weather, it may last for a number of months. In this fermental 
diarrhoea the color of the discharges is commonly some shade of green 
or greenish yellow, and the odor is often very offensive, sometimes being 
the excessively sour one which is supposed to arise from acid fermenta- 
tion, and at other times the extremely foul one of albuminous decompo- 
sition. The discharges are generally accompanied by considerable pain 
and a large amount of gas. They are usually not more than a dozen in 
number, and are larger in amount than those which occur in ileo-colitis. 
The symptoms are often so severe that the disease has a serious aspect, 
but in a considerable number of cases after the intestine has been thor- 
oughly emptied the temperature falls and the nervous symptoms subside. 
In some of the more severe cases certain special symptoms become so 
prominent as almost to produce different types of the disease. The most 
important of these are excessive vomiting, continuous hyperpyrexia, and 
extreme restlessness with insomnia. There is usually rapid and great 
loss of weight. In cases which are not prolonged by fresh irritation or by 
unwise treatment recovery often takes place quite rapidly. According to 
Morse, albuminuria occurs in about fifteen per cent, of all cases. Casts, 
usually hyaline and fine granular, occur in about sixty per cent, of the 
cases of albuminuria. The renal condition in these cases is a degenera- 
tive one, and not a true nephritis. 

Diagnosis. — When the attack is subacute, with slow onset, without 
vomiting, and Avith infrequent discharges, the diagnosis is not difficult, and 



DISEASES OF THE INTESTINE. 807 

is to be made from the nervous disturbances, which can usually soon be 
differentiated by the absence of fever and by rapid recovery. When, 
however, the onset is acute and is accompanied by vomiting, the diagnosis 
must often be held in abeyance, as the symptoms of high temperature, 
vomiting, and diarrhoea may be present in infants and young children in 
the initial stage of a number of acute diseases. The disease from which 
it is especially to be differentiated is cholera infantum. In fermental 
diarrhoea the prostration is much less, and the temperature after the 
early hours of the attack is much lower. The serous discharges and 
the continuous vomiting which soon arise in cholera infantum are quite 
different from the greenish discharges and the less frequent vomiting which 
occur in fermental diarrhoea. We must remember, however, that cholera 
infantum and the acute inflammatory intestinal diseases are usually pre- 
ceded for a number of days by this fermental form of diarrhoea, and that 
the special micro-organisms which produce the former disease gain an 
entrance for themselves and their toxines by means of the abnormal intes- 
tinal conditions produced by the fermental changes. The differential diag- 
nosis from ileo-colitis is considered under that disease, on page 822. It 
is also well to remember that gastro-enteric symptoms are often so pro- 
nounced during the early days of a pneumonia that they may mask the 
presence of that disease. 

Prognosis. — In previously healthy children the prognosis of fermental 
diarrhoea is good. It depends, however, upon the degree and the kind of 
fermental process which is causing the disease, and also on the amount of 
resistance to these processes which the individual possesses. It also de- 
pends upon the vulnerability of the individual to the other bacteria which 
may at any time complicate the disease, as in the more severe cases of the 
disease described above. The cases of infantile atrophy are especially 
liable to die when attacked by this as well as by any other form of intes- 
tinal disturbance. In these cases it seems as though the infant were totally 
unable to resist even a slight amount of toxic absorption. The prognosis, 
therefore, when an already debilitated child, or one with infantile atrophy, 
is attacked by fermental diarrhoea must always be guarded. It also de- 
pends upon how soon and in what way the disease is treated. The renal 
complications do not alter the prognosis. 

Treatment. — The treatment of fermental diarrhoea is to remove at 
once the source of the disturbance by thoroughly emptying the intestine. 
When the vomiting is excessive it is sometimes necessary to wash out the 
stomach, but, as a rule, this procedure is not indicated. A dose of castor 
oil, one teaspoonful for infants under one year, and two teaspoonfuls for 
older children, is the best initial treatment. When the stomach is so sen- 
sitive that it does not seem advisable to give castor oil, 0.06 to 0.12 
gramme (1 or 2 grains) of calomel can be given in divided doses. In the 
more severe cases, and when there is a tendency to a prolongation of the 
acute symptoms, irrigation of the intestine is indicated. Food should be 



808 PEDIATRICS. 

withheld for a number of hours, — at least half a day, if possible. Stimu- 
lants are indicated when there is much prostration. The only other 
drug which in my experience seems to be needed is bismuth subnitrate, 
which should be given in large doses until the disease has run its course 
and the diarrhoea has ceased. The amount of bismuth in the severe 
cases should be from four to eight grammes (sixty to one hundred and 
twenty grains) in twenty-four hours. 

Milk can in most cases be given after the first twelve to twenty-four 
hours if it is properly modified. It should contain from ten to fifteen per 
cent, of lime-water, and at first should have the percentages of all its ele- 
ments considerably reduced. The milk which is used for this purpose 
must be fresh, since it is not sufficient to sterilize it, as the toxic products 
of bacteria may still be present in it and thus add fresh irritation to that 
which has already been produced by the fermentation. In many cases it 
is impossible in the present state of our knowledge to determine what 
special form of fermentation is present. When acid fermentation appears 
to be prominent, the milk should be so modified as to contain a low per- 
centage of sugar, while when albuminous decomposition with its exces- 
sively foul odor is met with, the proteids should be reduced to a fraction. 
Whether this treatment will in the future be proved to be the best it is 
impossible to state, but on the ground that various forms of bacteria are 
the cause of these disturbances, and that the special form of bacteria 
which is producing them has been developed in the food on which it 
thrives best, it certainly seems reasonable, and should be adopted until 
further light is thrown upon the subject. 

When breast-milk or fresh modified cow's milk cannot be obtained, 
weak animal broths, such as those made from mutton, chicken, or beef, 
can be used. Opium is almost invariably contra-indicated in these cases, 
and serious results may arise from its administration. The peristalsis 
which occurs as the result of fermental irritation is a conservative process 
of nature, intended to carry away the morbid products which have re- 
sulted from the fermentation. Under these conditions the administration 
of opium prevents the elimination of the poison from the intestine and 
allows it to remain and produce still further irritation, or to be absorbed 
and give rise to still graver septic symptoms. Towards the end of the 
attack, when the intestine has been thoroughly emptied, small doses of 
opium in the form of tinctura opii camphorata may be used with caution 
to diminish pain and to control the excessive peristalsis which may result 
from nervous exhaustion after the disease has run its course. In these 
cases, however, stimulants are more valuable than opium. Extreme and 
continuous hyperpyrexia should be treated by bathing in water heated to 
32° C. (90° F.)and gradually reduced to 25.5° C. (80° F.). Excessive 
restlessness is to be treated with bromide of soda in doses of 0.012 to 
0.006 gramme (2 to 10 grains). In some cases subcutaneous injections 
of morphia, beginning with 0.0006 gramme (y-J-Q grain), is indicated. 



DISEASES OF THE INTESTINE. 809 

When a child in the warm weather has once had an attack of fer- 
mental diarrhoea it is very apt to have a number of attacks. Its diet, 
therefore, should be carefully regulated for a considerable period, and if 
possible it should be taken to the sea-shore or the country until the 
return of cool weather. 

As especial illustrations of the great variety of fermental diarrhoeas 
which are liable to be met with in warm weather the following cases may 
be taken as examples : 

A child three years old and perfectly well was attacked suddenly with abdominal 
pain, nausea, pallor, and prostration. He vomited once or twice and was found to 
have a temperature of 40° C. (104° F.). Within a few hours he began to have fre- 
quent faecal dejections of sour odor, lessened consistency, moderate amount, and a 
peculiar dark green color (Plate III., Xo. 18. facing page 84). This green is one of 
the more common colors met with in fermental diarrhoea. At first the discharges took 
place every hour, and later every three or four hours. After the first twenty-four hours 
the temperature became normal and in three or four days the diarrhoea ceased entirely. 

The next case was that of an infant thirteen months old. On entering the hos- 
pital it was much emaciated and had a slight diarrhoea, caused apparently by improper 
food. Its temperature was only slightly raised. On examining it nothing else abnor- 
mal was detected. The diarrhoea was infrequent and was not accompanied by any 
other especial symptoms. It soon began to improve, gained in weight, and had a nor- 
mal temperature. After it had been in the hospital one week it suddenly began to 
have diarrhoea characterized by large frequent discharges of lessened consistency, of 
foul odor, and of the color which is seen in Plate III., No, 19, facing page 84. which 
is a mixture of yellow and light and dark green. The discharge seemed from its foul 
odor to be an illustration of what is called albuminous decomposition. These colors 
are, however, only relative and are not diagnostic. In this acute attack the tempera- 
ture was raised at first but soon fell to a little above normal. The infant lost greatly in 
weight, became extremely emaciated, and looked as if it would die. The skin often 
became cold, and the prostration was extreme. These symptoms continued for three 
or four days, and the number of the discharges in the twenty-four hours varied from 
seven to ten. The symptoms gradually became less severe and the diarrhoea abated. 
Later the diarrhoea stopped entirely, and the infant gained rapidly in weight and 
strength. 

CHRONIC FERMENTAL. 

The cases of acute fermental diarrhoea at times are prolonged for 
many weeks, and even months, and thus produce a chronic form of diar- 
rhoea. This occurs especially in children who are the subjects of rhachitis, 
syphilis, and general tuberculosis, also in those with chronic broncho- 
pneumonia. The continuous administration of improper food may pro- 
duce this condition, as may also improper exposure from insufficient 
clothing. 

MECHANICAL. 

The mechanical diseases of the intestine are quite numerous, but with 
few exceptions are not of special importance medically, and belong rather 
to the province of surgery. 



810 



PEDIATRICS. 



DILATATION OF THE COLON. 

In comparison with dilatation of the stomach, dilatation of the colon 
is very rare except as a temporary condition. It is liable to occur at any 
time from an over-production of gas. If permanent, it is usually Congeni- 



ta. 164. 






Dilatation of colon. Male, 12 years old. 

tal, or it may be secondary to some congenital malformation such as 
stricture of the intestine. The chief symptoms are constipation and dis- 
tention of the abdomen. The condition is usually fatal, but adult life 
may be reached. The treatment is essentially surgical. 



The following case illustrates a dilatation of the colon, which was seemingly 
caused by a congenital stricture, and in which an artificial anus was made by Halsted. 
The child recovered from the operation, but later, owing to still further obstruction, 
he had to be operated on again and died. In this case the extreme distention of the 
abdomen, which was tympanitic through its whole extent, the evident obstruction to 
the faecal discharges, and the absence of symptoms pointing towards gastric disease, 
would suggest a dilatation of some part of the intestine, presumably of the colon. 



DISEASES OF THE INTESTINE. 811 

VOLVULUS. 
By volvulus is meant a twisting or bending of the intestine. This 
condition is more apt to occur in early life than later, possibly because of 
the greater proportionate length of the mesentery at this time, which 
allows the intestine greater latitude of motion. It occurs either by itself 
or in connection with intussusception, from which it is to be differentiated 
by the absence of blood and mucus in the discharges. 

INTUSSUSCEPTION. 

Intussusception or invagination is a condition in which a part of the 
intestine has passed down into another part. Under these circumstances 
there is an outer layer of intestine within which is the part of the intestine 
forming the invagination. Only a small portion of the intestine may be 
invaginated, or it may extend from the ileo-caecal valve to the rectum. 
Small invaginations are frequently found at the post-mortem examinations 
of infants and young children. These probably take place during the 
death-struggle, as no pathological condition is found in connection with 
them. This form is usually multiple and in the small intestine. The 
form of intussusception which occurs during life is very rare under three 
months, and is most common from the third to the sixth month. At this 
age the large intestine is shorter in relation to the small intestine than in 
the adult, while the mesentery is relatively wider, and thus allows much 
greater latitude for misplacement, especially of the caecum and colon. 
The etiology of intussusception is obscure, but it is probably directly due 
to increased local peristalsis. 

The pathological condition depends upon the tightness of the constric- 
tion and the length of time from the beginning of the obstruction. In 
some cases the incarcerated portion of the intestine is so little constricted 
that the bowel remains pervious. In other cases the constriction is so 
great that the tension of the intestinal capillaries quickly becomes so ex- 
treme that hemorrhage occurs, and inflammation, with resulting adhesions, 
is apt to follow rapidly. The intestine may not only be invaginated, but 
may be bent on itself, an important point to remember in regard to treat- 
ment. 

Symptoms. — The symptoms of intussusception are usually more acute 
in infants than in older children. In infants they are often at first rather 
obscure. Paroxysmal pain and discharges of blood from the rectum 
occur. Later the blood is mixed with mucus and looks like currant jelly. 
There is usually vomiting, which may be stercoraceous. The mind is 
clear, and in young infants the face is often tranquil between the parox- 
ysms of pain, so that on looking at the infant it would scarcely be sup- 
posed that a serious condition was present. Later, however, the face 
grows haggard and the eyes become sunken. During the first twenty-four 
to forty-eight hours, and even longer, the infants will often take their food 
quite readily. Tenesmus is at times present. There may be fever, espe- 



812 PEDIATRICS. 

cially when inflammation has occurred. The pulse is usually quickened. 
These symptoms all vary, and depend on the amount of the invagination. 
In some cases these are the only signs which indicate that there is abdomi- 
nal disturbance. In many instances, however, either at once or within a 
few hours, a tumor can be felt in the abdomen. 

Diagnosis. — The chief points in the diagnosis of intussusception^ are 
the occurrence of discharges of blood, vomiting, abdominal pain, and the 
detection of an abdominal tumor, usually on the left side of the abdomen. 
In these eases a careful rectal examination should always be made, for a 
tumor can often be found in this way when an external examination has 
failed to detect it. 

Prognosis. — Without treatment the prognosis is unfavorable, though 
there are a certain number of recoveries by spontaneous reduction, or 
rarely by sloughing of the invaginated portion of the intestine, which is 
then passed by the rectum. If death takes place, it usually occurs about 
the third or fourth day, or at any rate within a week, after the incarcera- 
tion is complete. When the incarceration is not complete the infant may 
live for many weeks, and in older children in rare instances the disease 
may become chronic. 

Treatment. — The treatment of intussusception, when the diagnosis has 
been definitely made, should be immediate, as in no other disease does a 
delay result in more serious consequences. Food and cathartics or laxa- 
tives are contra-indicated. If the infant shows signs of collapse, small 
quantities of brandy-and-water should be given. In the early hours of 
the attack an attempt should be made to reduce the intussusception by 
hydrostatic pressure. This can be easily done by having the infant's but- 
tock's somewhat raised and introducing water under a pressure of about 
one metre (3 J feet) by means of a fountain syringe. The water should be 
lukewarm, and should have dissolved in it salt in the proportion of one 
teaspoonful to a quart. The abdomen should be gently rubbed at the 
same time. In some cases this procedure results in a reduction of the 
intussusception, but when this is not accomplished an anaesthetic should 
be given and the attempt repeated. 

Even when inflammation has not begun and adhesions have not 
formed, the pressure of the column of water may fail to reduce the intus- 
susception, because the invaginated portion may be bent on itself, so that 
the hydrostatic pressure increases the obstruction rather than relieves if. 
When adhesions have taken place and when there is great congestion, as 
sometimes occurs during the first twenty-four hours of the attack, hydro- 
static pressure is usually unsuccessful and may be dangerous. If this 
method has failed, the infant should be placed at once in the hands of a 
surgeon, as under these circumstances an early laparotomy will give the 
most favorable results. 

The following case of intussusception illustrates the importance of not 
delaying operation. 



DISEASES OF THE INTESTINE. 813 

A male infant, six months old, nursed by its mother, and previously perfectly 
healthy, after a slight loss of appetite for several days began to have abdominal pain in 
the morning, and in the middle of the day had a discharge of blood from the rectum 
unmixed with faecal matter or mucus. The bowels had been thoroughly moved on the 
previous day, and there had been no tendency to constipation. During the afternoon 
there were five or six discharges of blood. In the evening the infant looked well and 
did not show any signs of discomfort except occasional slight attacks of abdominal pain 
and an indisposition to nurse. The rectal temperature was 39° C. (102.2° F.). An 
examination of the abdomen externally and by the rectum revealed nothing abnormal. 
The infant had a restless night, vomited several times after nursing, and had six dis- 
charges of blood. The temperature was 38.3° C. (101° F.), the pulse 135, strong and 
regular, and the generaL appearance good. The abdomen was soft and not tender on 
pressure, but towards the umbilicus, under the left costal border, a rather ill-defined 
cylindrical tumor could be detected. 

Hydrostatic pressure was employed to reduce the intussusception, but failed. The 
surgeon who saw the infant on the second day decided to wait twenty-four hours before 
performing laparotomy. On the following day the infant died suddenly. 

At the post-mortem examination nothing abnormal was found except an ileo-caecal 
intussusception. An examination of the invagination showed that the retained caecum 
was so twisted that the lower opening was directed to one side of the axis of the intestine, 
and the hydrostatic pressure from below must have simply packed the sac tighter and 
rendered reposition more difficult. The invagination involved 20 cm. (8 inches) of the 
intestine. The serous surfaces were firmly adherent through their whole extent, and 
considerable force was required to reduce the invagination without tearing it. The re- 
duction, however, was successfully accomplished, the adhesions giving way and the 
intestine being left uninjured and apparently healthy. This case illustrates how neces- 
sary it is to employ the most skilled surgical- aid in these cases. 

HERNIA. 
Hernia is essentially a surgical disease, and has been referred to in the 
division on diseases of the new-born. 

FISSURES. 

There are a number of lesions which occur about the anus in infants 
and young children which, though somewhat rare, should be recognized 
for purposes of differential diagnosis. They are, however, so purely sur- 
gical in their treatment that they need only be mentioned here. 

One of these conditions is that of fissure, which occurs either at the 
anus or more commonly a little distance from the orifice. Pruritus and 
reflex urinary symptoms are common. Defecation is often painful, and 
constipation of the spasmodic type may thus result. A general nervous 
irritation at times results from fissures of the anus which may seriously 
interfere with the nutrition of the child. The treatment is cleanliness 
and the application of boracic acid ointment or the stick of nitrate of sil- 
ver every two or three days. If these measures fail, stretching of the 
sphincter under anaesthesia usually cures the disease. 

PROLAPSE. 
Prolapse of the rectum is not uncommon in young children. It is 
usually produced by straining from various causes, especially in extreme 



814 PEDIATRICS. 

constipation or in diarrhoea. The wall of the rectum comes down through 
the anus, and is easily recognized by the appearance of the mucous mem- 
brane. The prolapse is ordinarily transitory, but in the more severe forms 
the rectum remains down. 

Treatment. — The treatment is to remove the cause. Constipation 
should be relieved first by enemata and then by keeping the movements 
of the bowels semi-liquid by means of gentle laxatives. The tenesmus ac- 
companying diarrhoea may be relieved by sponging with ice- water or by the 
use of 0.015 gramme (J grain) suppositories of cocaine. The child should 
be kept in bed for a number of days, the protrusion being gently pushed 
back each time that it comes down. The prolapse should be reduced with 
the fingers well oiled, the central portion being pushed back first. If the 
parts are very sensitive the reduction is facilitated by the application of a 
solution of cocaine. After reposition it should be kept in place by means 
of a pad and a T bandage. Under this treatment a large number of cases 
recover. The more serious and intractable cases, however, should be 
referred to a surgeon. 

POLYPI. 
Polypus of the rectum is more common in early life than at any other 
period. Hemorrhage from the rectum, when not due to constipation, 
diarrhoea, or fissure, usually arises from polypi. A careful examination 
for this growth should be made when rectal bleeding is frequent or large. 
Rectal polypi are of various sizes, and may be myxofibromata or adeno- 
mata. The surface of the polypus is usually smooth, and the pedicle is 
often long and thin. The diagnosis is easily made by a digital examina- 
tion. The treatment is either to twist or cut off the polypus. The growth 
is not apt to recur. 

HEMORRHOIDS. 
Hemorrhoids are rarely met with in infancy or early childhood, but, 
can occur and should be treated by the same methods as in later life. 

FTSTULJE. 
Fistulae in ano is not a very common condition in infancy or early 
childhood, but is met with at times. The condition has the same charac- 
teristics as in the adult, and should be treated in the same way. 

NEW GROWTHS. 

New growths in the enteric tract are very rare in infancy and child- 
hood, and are mostly confined to the myxomatous polypi of the rectum, 

B. Inflammatory. — The inflammatory diseases of the intestinal tract 
not otherwise classified comprise proctitis, appendicitis, and the various 
forms of ileo-colitis, which are usually designated as dysentery. This 
latter class represents a number of infectious diseases which are general 
in type, and each may be caused by a special organism, but in the present 
state of our knowledge they are most conveniently described in connec- 
tion with diseases of the intestine. 



DISEASES OF THE INTESTINE. 815 

PROCTITIS. 

Proctitis is an inflammation of the rectum, and may be acute or 
chronic. It is usually coincident with inflammation of the colon, but may 
occur alone as the result of trauma or the extension of inflammatory 
processes around the anus. 

Symptoms. — The symptoms are essentially pain, traces of blood mixed 
with mucus, and tenesmus. 

Diagnosis. — The diagnosis from reflex inflammatory conditions is made 
by direct inspection. 

Treatment. — The treatment is to keep the child in bed, to keep the 
faeces soft with laxatives, to cleanse the rectum, and, according to the 
especial lesions, use astringents or soothing injections. When there is 
pain or tenesmus, suppositories of opium and cocaine are indicated. 

APPENDICITIS. 

Etiology. — Inflammation of the vermiform appendix in children is 
most frequent between the ages of five and fifteen years, and is not of 
uncommon occurrence. It is very rare under two years. Several cases 
have been reported as early as seven weeks. Boys are more often attacked 
than girls, and in about the same proportion as in adults. Functional 
disturbances of digestion, constipation, diarrhoea, and indiscretions in diet 
are only remotely connected with the etiology of the disease. Foreign 
bodies are infrequent, despite the general opinion, but the presence in the 
appendix of faecal concretions, often resembling seeds and stones of fruits, 
are very common, but their exact relation to the primary cause of the 
inflammation is not clear. Direct trauma, as from a blow in the abdomen, 
is sometimes a definite exciting cause. The prevailing opinion is to con- 
sider the process an infective inflammation, though as yet no specific 
organism has been shown to cause it. On the contrary, cultures of the 
colon bacillus alone, or mixed infections of the colon bacillus associated 
with the streptococcus, pneumococcus, staphylococcus albus or aureus, 
the bacillus aerogenes, and certain undetermined anaerobic organisms are 
found. The transformation of the appendix into a closed tube is to be 
considered as a consequence rather than a cause of appendicitis (Brun). 

Pathology. — The pathological conditions occurring in the course of 
an appendicitis are exceedingly varied, and will only be outlined. In the 
early stages of a purely appendicular lesion, the appendix is in normal 
position and may show only slight swelling and congestion. Usually it is 
voluminous from extensive infiltration of its walls, very turgescent, and 
often shows spots of ecchymoses with intense congestion of the peritoneal 
coat. In more advanced stages the mucosa is soft and granular, some- 
times gelatinous, with ecchymoses and ulcerations. The muscular coats 
are thickened and their fibres often separated by minute or extensive ac- 
cumulations of pus. All these changes may develop in from twenty-four 



816 PEDIATRICS. 

to thirty-six hours after the onset of symptoms. Perforation and gan- 
grene of the appendix, in part or in whole, are simply further steps in the 
inflammatory process, and, according to Brun, are especially likely to 
occur in children. 

The inflammation is rarely confined to the appendix, but by extension 
involves the peritoneal coat of the appendix and the peritoneum itself. 
The subsequent course is very variable. The process may remain local, 
and lead to a peri-appendicular inflammation, in which the appendix, 
caecum, and end of the ileum are shut off from the rest of the peritoneal 
cavity by false membranes, with or without the formation of pus ; or the 
infection may spread directly from the appendix to the general peritoneal 
cavity, with the production of general septic peritonitis. The location of 
the pus in cases of abscess formation depends to some extent upon the 
location of the appendix, in which there is considerable variation. It 
may be either iliac, pre-rectal, sub-umbilical, retro-caecal, or lumbar in its 
disposition. 

A most malignant form of general peritonitis may follow a simple 
parietal appendicitis without perforation or gangrene of the appendix, and 
give rise to a clinical picture more suggestive of septicaemia than of 
peritonitis. 

A simple appendicitis, sometimes called catarrhal, may produce so 
much thickening of the walls and infiltration of the submucosa with leuco- 
cytes, and subsequent formation of granulation tissue, as to cause an 
obliteration of the lumen of the appendix. If the lumen is completely 
obliterated, it may render the patient immune to subsequent attacks, but 
if only partial, it favors the collection of pockets of pus and cyst-formation, 
and the organs is a constant source of danger. 

Ulcerative appendicitis may be caused by the presence of concretions 
or by the action of micro-organisms. The presence of concretions, how- 
ever, may not be accompanied by any inflammatory or necrotic reaction. 
Typhoid and tubercular ulcerations of the appendix are not uncommon 
in their respective diseases, and an actinomycotic ulcer has also been 
described. 

Symptoms. — Sudden pain in the abdomen, referred to the umbilicus or 
to the right iliac fossa, with tenderness on deep pressure in the region of 
the appendix, associated with a fever of moderate or high grade and 
gastro-intestinal symptoms, usually mark the onset of an acute inflamma- 
tion of the appendix. Clinically it is convenient to distinguish between 
certain types of the disease. 

Simple Appendicitis. — This is the least severe of the acute forms, and 
is characterized by its sudden onset and short duration. Without any 
prodromal symptoms the child is seized with sudden, severe abdominal 
pain at about the level of the umbilicus and more to the right than to the 
left. Vomiting, in some cases only nausea, follows. There is moderate 
fever. The pain is continuous, and the bowels are usually constipated. 



DISEASES OF THE INTESTINE. 817 

Tenderness over the region of the appendix with a unilateral rigidity of 
the muscles is the most important sign by which we exclude other causes 
of abdominal pain. The temperature is moderate, 23.5° to 24.1° C. (100° 
to 101° F.), lasting a day or two. The acute symptoms subside in from 
twenty-four to forty-eight hours, but the tenderness is apt to remain for 
several days, at the end of which time the abdomen is sometimes so re- 
laxed as to enable one by careful examination to feel the slightly thick- 
ened appendix. These mild cases probably occur much oftener in children 
than are diagnosed. 

Appendicitis "with Periappendicular Peritonitis. — This is the more 
common form, formerly recognized as perityphlitis, and in its mildest 
grade is not to be distinguished clinically from the severer types of a 
simple appendicitis. The initial symptoms are more exaggerated, but are 
the same in character as in a simple appendicitis. The digestive symptoms 
are much more pronounced. The vomiting is apt to be repeated, and the 
temperature much higher, 39° to 40° C. (102.2° to 104° F.). The pulse 
is rapid, 112 to 120 per minute, and the pain and localized tenderness is 
more intense. After a lapse of some hours, if the abdomen is not too 
tense, Ave may sometimes feel in the right iliac region an indistinct thick- 
ening, sometimes a definite mass, but the swelling may not be located 
until the child is under the influence of an anaesthetic. There is apt to 
be leucocytosis, though one must not be misled by a normal white blood 
count. In some cases, under expectant treatment, these symptoms will 
gradually subside in the course of a week or ten days, and with the alle- 
viation of the acute pain and tenderness the swelling of the appendix and 
surrounding tissue is more readily recognized. In time this mass may 
entirely disappear so far as external palpation can determine, or, on the 
other hand, some induration may remain after complete establishment of 
health. 

If the inflammatory process ends in abscess formation the persistence 
of the fever and the presence of leucocytes aid in the diagnosis. The 
return of the fever after its subsidence is also indicative of the advent of 
suppuration. The absence of fever, however, cannot be taken as positive 
evidence of the absence of pus. If the swelling increases in size or if it 
remains stationary we strongly suspect that there is a local accumulation 
of pus. If the pus has once formed it may terminate by absorption or 
by perforation externally or into some portion of the intestines, vagina, or 
bladder, but — and this should always be borne in mind by the physician 
who takes the responsibility of expectant treatment — it may rupture into 
the peritoneal cavity, usually with the result of a fatal septic peritonitis. 

Appendicitis with General Suppurative Peritonitis. — Aside from 
those cases of general peritonitis which are caused by a rupture of an 
appendix abscess into the peritoneal cavity, there are others of general 
peritonitis in which the infection starts from a diseased appendix with 
symptoms of such rapid development as to indicate a general peritonitis 

52 



818 PEDIATRICS. 

almost from the very beginning. There is sudden severe pain in the 
region of the umbilicus rapidly spreading over the whole abdomen, but 
with its greatest intensity on the right side. The vomiting is incessant, 
and the constipation so sudden and complete as to suggest intestinal ob- 
struction. The temperature rises suddenly to 39° to 40° C. (102.2° to 
104° F.), and the pulse is increased to 130 to 140 per minute. The ab- 
domen rapidly becomes rigid throughout, and deep palpation is impossible. 
The tenderness is general, but most marked on the right side in the 
neighborhood of the appendix. The symptoms progress rapidly. The 
vomiting of bile is followed by that of faeces. The abdomen becomes dis- 
tended. The respiration is labored. Delirium often sets in. Aside from 
the localized tenderness and rigidity, the examination of the abdomen is 
negative, for the amount of intraperitoneal fluid is too small to be recog- 
nized by percussion, though at times a rectal examination gives evidence 
of fluid in the cul-de-sacs. Without an early operation, death usually 
ensues in these cases in from two to four or five days. 

There is still another form of appendicitis with diffuse peritonitis, de- 
scribed by Brun, Jalaguier, and others, Avhich is the most malignant and 
rapid of all, and in its course suggests a septicaemia having its origin in a 
virulently infected appendix. Its onset is quite different from the type of 
disease just described. It begins like an attack of acute intestinal indi- 
gestion with vomiting and foetid diarrhoea, rarely, if ever, Avith constipa- 
tion. Neither the pain nor the tenderness in the iliac fossa is so marked 
as in the other cases. The abdomen is soft, flat, and easily palpable, and 
with almost complete absence of resonance on percussion. The progress 
is rapid. The features are anxious, leaden-colored, the eyes sunken and 
surrounded by dark rings. The thirst is keen, the respiration rapid and 
shallow. There is extreme restlessness. The temperature at the first 
may reach 39° C. (102.2° F.), but on the second day is more apt to be 
37° C. (98.6° F.) or below, in striking contrast to the weak, rapid pulse 
of 150 to 160. The mind remains clear to the end, without any change in 
the abdominal symptoms, and death often supervenes within thirty-six 
to forty-eight hours, rarely extending beyond three or four days. 

Chronic Appendicitis. — An appendix once inflamed is prone to re- 
current attacks, with the train of events connected with the primary 
attack. The cause for this probably lies in an obliterative appendicitis 
with or without adhesions, or perhaps from a localized abscess circum- 
scribed by dense fibroid tissue. The attacks may recur at intervals of a 
few months, and finally cease or develop into an acute attack which may 
run a typical course. Chronic appendicitis may, however, manifest itself 
from the beginning as indefinite twinges of pain in the right iliac fossa, 
brought on especially by over-exertion and fatigue, without ever develop- 
ing alarming symptoms, and with but little else in the way of symptoms ; 
on the other hand, these inconstant pains may be prodromal symptoms 
of a susceptible appendix, which later becomes acutely inflamed. 



DISEASES OF THE INTESTINE. 819 

Diagnosis. —The diagnosis of appendicitis in young children is often 
made difficult by the inability of the child to locate accurately his sense 
of pain, and to appreciate the distinction between pain and tenderness. 
Moreover, the contraction of his abdominal muscles and his inability to 
relax them at will renders the result of palpation less certain. The 
presence of fever and localized tenderness in the right iliac fossa are the 
principal points in the exclusion of hepatic and renal colic. Intestinal 
colic is more often associated with diarrhoea than with constipation, and 
here again the localized tenderness is a crucial point in the diagnosis. It 
is well established that in pneumonia in children the pain is frequently 
referred to the abdomen, but careful attention to the symptoms and 
course of the disease will enable one to distinguish between the two con- 
ditions. An appendix abscess arising from an appendix unusually placed 
might easily be confounded with a perinephritic abscess, but in either 
case operation is indicated, and the error in diagnosis should not prejudice 
the interests of the child. Appendicitis with the sudden onset of septic 
peritonitis may readily suggest an intestinal obstruction, but the fever, 
localized tenderness, and leucocytosis are not likely to occur in the latter 
condition. In intussusception the straining, tenesmus, and small and 
frequent discharges of blood and mucus, and the sausage-like tumor, 
which can often be felt in the region of the transverse colon, usually suf- 
fice for a diagnosis. Moreover, appendicitis is very rare under two years, 
and intussusception is very common. In certain cases the two conditions 
simulate each other very closely. Perforation of gastric ulcer, pus tubes, 
and pelvic peritonitis, abscess of the broad ligament, acute pancreatitis, 
appendicular hypochondriasis and hysteria, which may in the adult be 
mistaken for appendicitis, are not likely to occur in infants and young 
children, but in older children should be borne in mind. An acute in- 
flammation of the gall-bladder and appendicitis are often confounded, and 
an unusual position of the appendix should always be remembered. 

Prognosis. — The prognosis depends largely upon how early the diag- 
nosis is made and the skill of the surgeon who is called for consultation 
and operation. Cases undoubtedly recover in many instances without 
operation, but the extreme gravity of the results of an extension of the 
inflammation to the peritoneum, and the realization that this accident may 
occur at almost any time, even in the cases which are apparently running 
a mild course, render general statistics of little value in the considera- 
tion of an individual case. We should not lose sight of the fact that in 
infancy we see most frequently the very severe and acute forms of the 
disease, and there is the special tendency to perforation and gangrene and 
extension to the peritoneum, with its very serious consequences. 

Treatment. — Personally, I consider the disease one for surgical obser- 
vation and treatment. It is safer to call the surgeon in consultation early 
than late, and if the diagnosis is determined it is wiser to trust to his 
judgment as to the expediency of immediate or delayed operation than 



820 PEDIATRICS. 

for the physician himself to attempt to decide. There is no medical treat- 
ment other than that which is purely symptomatic. Absolute rest in 
bed, irrespective of the severity of the symptoms, is of first importance ; 
local applications of ice should be used to control the pain, or, if the 
child objects, as is frequently the case, hot fomentations should be tried. 
Cathartics and laxatives should be avoided, and the bowels moved by 
enemata. Blisters should not be used. Opium is strongly objected to 
by surgeons as tending to mask the symptoms ; if it can be avoided, it is 
far better to do so ; but very small doses, sufficient to keep the patient 
from excessive pain and fairly quiet, are probably in children a lesser 
danger than that which would be caused by hours of pain, crying, and 
intense restlessness. If no operation could be performed I should prefer 
to trust to opium in the early stages rather than to cathartics. 

ILEO-COLITIS. 

General Etiology. — Under the term ileo-colitis are included all the 
more marked and grave lesions of the intestine. They are commonly 
grouped under the name dysentery, but as our knowledge of them in- 
creases it is becoming evident that any such general term as dysentery is 
inadequate to cover what will, in all probability, be proved to be a 
number of diseases, each arising from its own specific organism. 

All these forms of ileo-colitis (dysentery) are considered to be in- 
fectious. They may occur as acute primary diseases, but are usually 
secondary to the fermental diarrhoeas, and sometimes to the infectious 
diseases, especially measles. The sporadic cases have not as yet been 
sufficiently studied bacteriologically to allow us to come to any definite 
conclusions concerning them etiologically. Flexner has, however, shown 
that it is entirely possible that two specific organisms may be responsible 
for both the epidemic and endemic varieties of what has been called 
tropical dysentery, and that they consist of (1) a bacillary and (2) an 
amoebic form. 

Amoebic ileo-colitis is so well recognized as a specific infectious dis- 
ease that it has already been described with the other infectious diseases, 
on page 501. 

In regard to the bacillary form much light has recently been thrown 
by the work of Duval and Bassett, under the supervision of Flexner, and 
by others working along similar lines. It is probable that all, or nearly 
all, of the cases of diarrhoea associated with blood and mucus are due to 
an infection by Shiga's bacillus, of which two forms may be definitely 
separated, which give rise to the same clinical manifestations, so far as is 
now known, but which show certain differences in their growth on culture- 
media and in their reaction to agglutination. It is also possible that these 
same organisms are the direct cause of many of the fermental diarrhoeas. 
The whole subject of the etiology of fermental diarrhoea and of ileo-colitis 
is at present undergoing an exhaustive reconsideration. Bacteriological 



DISEASES OF THE INTESTINE. 821 

investigations have not been carried sufficiently far as yet to justify us in 
drawing positive conclusions in regard to the occurrence of these organ- 
isms in the diarrhoeas of infants. It is probable that the investigations now 
in progress will materially alter our views as to the etiology, pathology, 
and even as to the treatment of these diseases. 

Variations in Type. — The divisions which have been adopted to sim- 
plify the subject are (1) simple catarrhal inflammation, which includes the 
non-ulcerative form of follicular inflammation, (2) follicular inflammation, 
and (3) a pseudo-membranous inflammation. 

The pseudo-membranous form of ileo-colitis may be primary or 
secondary. In the primary form it represents what is usually spoken 
of as epidemic or sporadic dysentery. The secondary form is that which 
follows certain infectious diseases. 

The pathological lesions found in connection with the catarrhal and 
non-ulcerative follicular and the ulcerative follicular inflammations ap- 
proach each other so closely and the symptoms are so. similar that the 
clinical distinction between the two conditions is very uncertain. More- 
over, it is impossible at present to state what relation these different 
pathological lesions bear to the different etiological factors. It is quite 
possible that the same clinical symptoms and the same pathological 
lesions may be caused by several different varieties of organisms. 

Acute Ileo-Colitis. — Symptoms. — The symptoms of the various forms 
of acute inflammatory ileo-colitis vary greatly, as a rule, but in a general 
way they can often be recognized by a group of symptoms which differ from 
those of the non-inflammatory diarrhoeas, spoken of as fermental diarrhoea 
and cholera infantum. The symptoms, however, of these different forms 
of ileo-colitis are very unsatisfactory and unreliable for differential diag- 
nosis. 

The onset of the disease may be preceded by a fermental diarrhoea, 
or it may be acute from the beginning and have prodromal symptoms of 
no more than a few hours. The temperature is elevated, the pulse is 
accelerated, and the infant loses rapidly in weight and strength. The dis- 
charges are perhaps ten or twenty, or even more, in the twenty-four 
hours, but are comparatively small in amount. Where the lesions are in 
the rectum there is tenesmus both before and after the discharge, and in 
the beginning of the attack an almost constant desire to have a move- 
ment. The discharges contain faecal matter at first, but soon become 
small, and consist of mucus, sometimes with pus, blood, and shreds of 
membrane. The odor may be very offensive, but when the mucus pre- 
dominates there is very little odor. The color and consistency are ex- 
tremely variable, but generally the consistency is lessened and the color 
is a mixture of green, brown, and yellow. The blood is usually from 
congestion of the blood-vessels and straining, rather than from ulceration, 
so that we cannot determine from the presence of blood whether ulcera- 
tion is present or not. At first the abdomen may be soft and not tender, 



822 PEDIATRICS. 

but later in the disease it becomes distended, tympanitic, and somewhat 
tender, especially along the course of the colon. Vomiting may occur at 
times. In severe cases the child is very restless, and there may be de- 
lirium and convulsions. The appetite is usually much lessened. The 
urine is nearly always diminished in quantity, is high-colored, and some- 
times contains a small amount of albumin, especially when the tempera- 
ture is high. Casts may also be found. The renal condition in these 
cases is a degenerative one, and not a true nephritis. Acute glomerular 
nephritis is rare. When there is much tenesmus and straining, and when 
the discharges are especially frequent, prolapse of the rectum may occur. 
The discharges often cause great irritation around the anus and on the 
buttocks. 

Although there are no symptoms typical of the different forms of acute 
ileo-colitis, certain peculiarities may sometimes be noted. 

It is usually found in the simple catarrhal ileo-colitis, when ulceration 
has not taken place, that the symptoms are milder and that there is apt 
to be vomiting. The cases generally begin to improve in one or two 
weeks, and recover entirely in another week. The children are usually 
a long time in regaining their strength, and relapses are quite common in 
this form if the diet is not carefully regulated. Sometimes, however, 
simple catarrhal ileo-colitis may be represented by symptoms of a very 
severe type and prove rapidly fatal. 

When follicular ulceration has taken place the stomach is not apt to 
be much involved, the temperature is not, as a rule, high, and the course 
of the disease is rather slow, irregular, and prolonged. The infant fails 
steadily and commonly dies. When the inflammation is simply follicular, 
without ulceration, the cases are very apt to recover. 

Pseudo-membranous ileo-colitis is rare in infants, but when it occurs 
it is the most severe of all the forms. I have already stated that it is 
this form which is usually spoken of as epidemic or sporadic dysentery. 
The temperature is high,— 39.4°, 40°, or 40.5° C. (103°, 104°, or 105° 
F.). There are apt to be blood and membranous detritus in the dis- 
charges. The progress of the disease is usually rapid and without remis- 
sion, and death may take place in a week or ten days. The nervous 
symptoms, such as restlessness and delirium, are quite prominent. 

Diagnosis. — These forms of ileo-colitis are diagnosticated from the 
fermental diarrhoeas by the continued heightened temperature, the more 
frequent discharges, the small amount in each, the presence of blood or 
membrane, and the tenesmus. They may be differentiated from cholera 
infantum by the absence of continuous and excessive vomiting and by the 
serous discharges of the latter disease. The diagnosis, however, can be 
made positively only by finding shreds of membrane in the discharges. 
It is probable that the examination of the blood of the patient in refer- 
ence to its agglutinating relation to the several strains of organism causing 
ileo-colitis may in the future enable us to differentiate the various types of 



DISEASES OF THE INTESTINE. 823 

infection. We cannot, however, say at present whether such information 
will throw much light on the particular pathological lesions present. 

Prognosis. — The prognosis of ileo-colitis, when ulceration has not 
occurred, is usually favorable, the duration of the disease being a few weeks. 
Some cases, however, are more severe, and sometimes prove fatal in a 
few days. When there is ulceration, the prognosis is rather unfavorable. 
When there is a diminution in the frequency of the discharges and faecal 
matter begins to reappear, and when the nervous symptoms and exhaus- 
tion lessen, the prognosis is good ; but when the symptoms increase in 
severity and the face looks pinched, when intractable vomiting arises and 
the nervous symptoms predominate, the prognosis is very unfavorable. 

The prognosis is less favorable when the ileo-colitis is complicated by 
broncho-pneumonia or tuberculosis. It is much influenced by the time 
of the year at which the attack takes place, the prognosis being worse if 
the disease occurs at a time when the convalescence is during a long 
heated period. The prognosis is also Avorse when the infants have to be 
treated in crowded cities and in the midst of unsanitary surroundings. 

Treatment. — The treatment of these forms of ileo-colitis should 
usually be in the beginning the same as has already been described for 
fermental diarrhoea. It may in this sense be spoken of as prophylactic, 
for in a large number of cases the organisms which produce ileo-colitis 
find a means of entrance through the irritated mucous membrane pro- 
duced by a preceding fermental diarrhoea. When the case is seen in its 
earlier stages, a mild laxative should be given, in order to clear away, so 
far as possible, the pathogenic organisms, which are present in large num- 
bers. Small doses of castor oil act most efficiently, and can usually be 
given, especially to infants, without causing nausea or gastric irritation. 

In addition to this treatment by the mouth, thorough irrigation of the 
colon should be employed. This should be done twice in the twenty- 
four hours with warm sterilized water containing 3.75 grammes (1 drachm) 
of borate of sodium to the pint of water. Two to four quarts of water 
should be allowed to flow in and out of the intestine at each irrigation. 
After the irrigation, small enemata of thin mucilage, about 120 c.c. (4 
ounces), containing 15 grammes (J ounce) of bismuth in suspension, may 
be given once in three or four hours. 

According to the degree of pain, restlessness, and general discomfort, 
a slight amount of opium can be given in these injections, but in all 
cases this drug should be administered with great care ; 0.03 c.c. (J 
minim) of tincture of opium in the first year, and 0.06 c.c. (1 minim) in 
the second year, once in five or six hours, will usually be sufficient to 
make the infant comfortable. The effect of the opium should be carefully 
watched, and the dose increased or decreased as is necessary. 

When the tenesmus is extreme, it is well to use suppositories con- 
taining from 0.015 to 0.03 gramme (J to J grain) of cocaine. These 
suppositories will often give great relief if the painful lesions are mostly 



824 PEDIATRICS. 

in the rectum, but when the lesions are higher in the colon they are not 
of much value, and when the tenesmus is continuous and exhausting, 
and the suppositories ineffective, a subcutaneous injection of morphia, 
0.003 gramme (^ grain), with atropia, 0.0003 gramme (^ grain), can 
be given. 

The use of antiseptics by the mouth I do not recommend. Bismuth 
can be given by the mouth with some advantage in these cases, but the 
dose must be considerable to accomplish good results. 1.87 gramme (J 
drachm) in the twenty-four hours should be given to a child a year old, 
and for older children the dose should be proportionately increased. 
Brandy can be given with benefit at all stages of the disease if there is 
evidence of a weakened heart, or if much exhaustion is present. 

A very limited amount of food of any kind should be given during 
the first twenty-four hours. Sterilized water containing brandy and barley- 
water had better be given at first, as it has been found that when a sterile 
liquid is taken by the mouth the number of bacteria in the intestine dimin- 
ishes rapidly. After this preliminary treatment if a perfectly fresh milk 
can be obtained it may be used, if sterilized and modified in its various 
elements so as to be adapted to the digestion of the especial case. A low 
percentage of fat and sugar, such as 2 and 5, and a proteid percentage 
of about 0.50, is a very good prescription to begin with. It should be 
gradually increased by the addition of whey until the full amount of 
diluent is whey, then the fat and casein should be by degrees increased. 
Weak broths can also be given to older children. 

Chronic Ileo-Colitis (chronic dysentery). — Etiology. — In some cases 
of ileo-colitis, after the acute symptoms have ceased, the diarrhoea con- 
tinues for many months, and the disease becomes chronic. 

Pathology. — The pathological conditions most commonly found in 
these chronic forms of ileo-colitis are great thickening of the muscular tissue,, 
pigmentation of the mucous membrane, and very extensive ulceration. 

Symptoms. — There is no especial pain or tenderness, and the tempera- 
ture may be normal. The appetite often returns, but the child does not 
gain in weight, or it loses. The discharges are not so frequent as during 
the acute stage of the disease, varying from six or eight to two or three 
in the twenty-four hours. The discharges have a lessened consistency,, 
and contain mucus and undigested food. There may at times be exacer- 
bations of the symptoms, and the children are very apt to die of some 
intercurrent disease. The duration may be many months. 

Treatment. — The treatment is, if possible, a change of air, and is 
otherwise essentially dietetic. 

The rules already given for the treatment of the chronic forms of 
fermental diarrhoeas are also applicable to this class of cases. 

As illustrations of the difficulty and in many instances the impossibility 
of diagnosticating intestinal lesions, the following cases, which were under 
my care, are of interest. 



DISEASES OF THE INTESTINE. 825 

One of these cases was that of a little girl, five years old, who during 1 the hot 
weather in August had been having a slight attack of fermental diarrhoea, which began 
with vomiting, headache, and a slight rise of temperature lasting a few hours. This 
was soon followed by four or five greenish-yellow discharges in the twenty-four hours, 
and a normal temperature. The diarrhoea diminished in two or three days, and the 
child seemed much better, but after a few days she was suddenly attacked with a 
temperature of 39.4° to 40° C. (103° to 104° F.) and with frequent discharges of 
mucus and blood. She lost rapidly in weight, and looked very sick. After twenty- 
four hours, however, the movements became normal ; and on the following day, 
although left weak and prostrated, she seemed perfectly well, and had no return of 
the attack. During the acute symptoms it seemed as if she were attacked by one 
of the more severe forms of colitis, but the rapid recovery left the diagnosis very- 
doubtful. 

The next case was that of a child, seven years old, who entered my wards at the 
Boston City Hospital with a history of having had a slight diarrhoea for a few days. The 
temperature was but slightly raised. The movements were infrequent, of a greenish- 
yellow color, and contained no blood or membrane, and scarcely any mucus. The 
child seemed fairly well on entering the hospital, but during the following few days 
became much exhausted. Although no other intestinal symptoms appeared, he sank 
rapidly, and died apparently from exhaustion. The autopsy showed extensive lesions 
of the whole colon, the mucous membrane was greatly thickened, and there were 
numerous ulcerations. 

The third case was that of a boy, four years old, who was brought to the Children's 
Hospital for frequent vomiting following an attack of diphtheria. During the first 
three weeks that he was in the hospital the vomiting was the chief symptom. He was 
fed by nutritive enemata, and improved in his general strength. Later, however, he 
became very much emaciated, the vomiting increased in frequency, and a few days- 
before he died there was a slight diarrhoea. The temperature was normal or sub- 
normal during the whole course of the disease. During the last four or five days the 
symptoms had pointed almost entirely to the stomach, but the post-mortem exami- 
nation showed nothing abnormal in the stomach, lungs, heart, kidneys, or spleen. 
The mesenteric glands were swollen in the region of the ileo-csecal valve. The walls- 
of the ileum and colon were thickened and reddened. There was a slight deposit of 
fibrin over part of the mucous membrane of the ileum. The lower 35 cm. (13f 
inches) of the colon were found to be much thickened, the inner surface was of a dark- 
greenish color, and beneath it the tissue was deeply injected. The thickening seemed 
largely due to an exudation on the mucous membrane, which could not be torn away. 
The thickening ended quite sharply, but on some of the valvulse coimiventes above a 
similar membranous deposit could be found. In the colon the thickening was most 
marked in the caecum and the rectum, and least so in the transverse colon, and the 
process seemed older than in the ileum. Cultures from the various organs were nega- 
tive. Various organisms were found in the ileum, but none that seemed to be of 
especial significance. 

The following cases and figures illustrate varieties of ileo-colitis and 
show how with our present knowledge it is usually impossible to diag- 
nosticate the especial lesions during life. 

The first specimen (Fig. 165) is a portion of the colon of an infant 
who during life had only a slight diarrhoea. 

The lesion is quite marked and simulates closely the hyperplasia of 
Peyer's patches which is commonly seen in typhoid fever; but in this, 
case it represents merely intestinal irritation. 



826 



PEDIATRICS. 



This next specimen (Fig. 166) was found at the autopsy of a little 
girl, three years old, who had been under the care of Dr. Webber. 

The child was attacked with excessive vomiting after eating pigs' feet, and the 
vomiting continued until her death, five days later. The lesions were chiefly in the 
upper part of the colon, and consisted of a general non-ulcerative follicular inflamma- 
tion. The hyperplasia of Peyer's patches was extreme. 

Fig. 165. 




Hyperplasia of the lymph-follicles. Warre 



Harvard University. 



The following interesting specimens of lesions of colitis occurred in 
the hospital service of Dr. Northrup, and are now preserved in the 
Museum of the College of Physicians and Surgeons, New York. 

Fig. 167 shows an acute catarrhal follicular inflammation without 
ulceration. 



The infant, a male, two years old, had a history of diarrhoea and general debility 
lasting two weeks. While in the hospital he had a continued high temperature, which 
at one time reached 40° C. (104° F.). The symptoms were mostly of a cerebral type, 
and the abdominal symptoms were not severe or prominent enough to indicate the 
marked lesions which were found at the autopsy. The post-mortem examination 
showed the following conditions : Brain normal. Stomach congested. The small in- 
testine contained a large amount of thick mucus. The solitary follicles were enlarged, 
rather more in the upper third of the intestine. Peyer's patches were markedly 



Fig. 166. 




Non-ulcerative follicular inflammation. Simple hyperplasia of lymph-follicles. 
Female, 3 years old. Warren Museum, Harvard University. (Page 826.) 



Fig. 167. 




Colitis follioularis non-ulcerativa. Male, 2 years old. Museum of the College of Physicians 
and Surgeons, New York. (Page 826.) 



FiCx. lfi 




Colitis follicular is non-ulcerativa. (Page 8: 



Fig. 169. 




Hyperplasia of lymph-follicles (solitary glands). Muc. Mem., mucous membrane ; Lym. Ts. 
lymph-tissues; Mus., muscle; Fol., follicles. (Page 827.) 



Fig. 170. 



Muc Mem 




Muc. Mem., mucous membrane ; Fob, follicles ; Submuc, submucous tissue ; Mus., muscle. 

(Page 827.) 



Fig. 171. 




Ileocolitis ulcerativa follicularis. Infant, 16 months old. Museum of the College of Physicians 
and Surgeons, New York. (Page 827.) 



Fig. 172. 




Acute ulcerative catarrhal colitis. Female, 3 months old. Museum of the College of Physicians 
and Surgeons, New York. (Page 827.) 




inflammation of follicles and surrounding parts of colon. The process has gone on to necrosis. 
3 months old. Warren Museum, Harvard University. (Pairo 827.) 



Female 



Fig. 174. 




Pigmented follicular ulcers of colon. Chronic catarrhal ulcerative follicular colitis. Museum of the 
College of Physicians and Surgeons, New York. (Page 828.) 



Pig. 175. 




Pseudo-membranous colitis. Child, 3% years old. Museum of the College of Physicians and 
Surgeons, New York. (Page 828.) 



Fig. 176. 




Pseudo-membranous colitis. Female, 4 years old. Ps. M., pseudo-membrane ; M. M., mucous 
membrane ; Subm., submucosa; Mus., muscle ; Per., peritoneum. (Page 828.) 



Fig. 1' 



Nee. Muc. Mem 



Inf. Muc.Mem 




Mus. 
5ubmuc 



Nee. Muc. Mem., necrotic mucous membrane ; Inf. Muc. Mem., inflamed mucous membrane 
Mus., muscle ; Submuc, submucosa. (Page 828.) 



DISEASES OF THE INTESTINE. 827 

swollen, and a few solitary follicles appeared to be ulcerated. The mesenteric lymph- 
glands were enlarged. The mucous membrane of the colon was swollen ; the follicles 
were enlarged and somewhat pigmented, but not ulcerated. 

Fig. 168 shows another portion of the colon taken from the same 
infant. 

The solitary follicles are very much enlarged, and in Peyer's patches, 
which are in the middle of the specimen, the hyperplasia is of a very 
high degree. 

Figs. 169 and 170 illustrate microscopic sections of this form of 
follicular inflammation. The former showed the great enlargement of 
the lymph-follicles ; the latter showed the inflamed condition of the 
mucous membrane as well as the enlarged lymph-follicles. 

The next specimen (Fig. 171) was taken from an infant sixteen 
months old. 

The infant before entering the hospital had had occasional attacks of diarrhoea for 
three months, presumably caused by improper feeding. Soon after entering the hos- 
pital it rapidly grew worse and died. 

The autopsy, made by Northrup, gave the following results : No tubercular lesions. 
Bronchial lymph-follicles enlarged. Small intestine showed much swelling and con- 
gestion of Peyer's patches, but no ulceration. The colon showed extensive follicular 
ulcerations. In the small intestine and the colon were found masses of strings of 
greenish mucus ; no blood. 

The next specimen (Fig. 1 72) was taken from a female infant, three 
months old. 

The infant on entering the hospital was somewhat rhachitic, emaciated, and fretful. 
There were no vomiting and no fever. It took very little nourishment, and at this time 
was having one large, watery, faecal discharge daily. The faecal movements were 
greenish yellow. The infant apparently improved for about a week. The temperature 
was then found to have risen, and during the next week it varied from 36.6° to 37.7° 
C. (98° to 100° F.). During the next week the temperature was sometimes subnormal. 
At the end of three weeks the infant began to fail rapidly without any discoverable 
cause, and died suddenly. 

The autopsy was made by Northrup, and showed the following lesions : the mucous 
membrane of the ileum was swollen, and the lymph-follicles were enlarged, but not 
ulcerated. The report of the examination of the colon was as follows : numerous 
ulcers, some round and some irregular in shape ; an increased production of mucus ; 
a profuse growth of connective tissue between the tubules, wiin disappearance of the 
tubules ; necrosis of the new tissue so as to form ulcers ; the solitary follicles swollen, 
but not concerned in the formation of ulcers, which were simply necrotic. No amoebae 
found. The process was one which would ordinarily come under the head of acute 
catarrhal colitis. 

The next specimen (Fig. 1 73) was taken from an infant three months 
old, in the hospital under the care of Dr. Holt. 

The child had no acute symptoms, but had never been well, and for some time 
had been losing in weight and strength. It entered the hospital for vomiting and 



828 PEDIATRICS. 

diarrhoea. Nothing was found on physical examination. While in the hospital it had 
from six to eight loose greenish discharges in the twenty-four hours, and vomited 
occasionally. Its temperature varied from 37.2° to 38.3° C. (99° to 101° F.). It 
gradually failed, and died twelve days after entrance. 

The post-mortem examination showed extensive follicular ulcerations of the colon, 
especially in the lower part of the specimen, where there was a large ulcer. The tissues 
around the follicles are also involved, and the process had gone on to necrosis. 

The next specimen (Fig. 174) was taken from a male infant six months 
old. 

The infant entered the hospital in a very wasted condition, and died in a few days- 
without any special abdominal symptoms. The autopsy, made by Northrup, showed 
numerous superficial abscesses on the body, a general bronchitis, and a beginning- 
broncho-pneumonia. The lesions in the intestine were an inflammation of the solitary 
follicles of the ileum and of the colon, with small ulcerations at the apices of the 
follicles in the colon, no ulcers being present in the ileum. In the specimen the ulcers 
were pigmented, which denoted a chronic condition. The apices of the follicles are 
sometimes found pigmented as the result of post-mortem changes, and may simulate 
these ulcerations. 

The next specimen (Fig. 175) was one of pseudo-membranous colitis.. 

This child, three and a half years old, a patient of Northrup' s, entered the hos- 
pital in a very reduced condition following an attack of whooping-cough. It was 
attacked with diphtheria, and during the ten days that it was suffering from this disease- 
there was a slight amount of diarrhoea, but no pain and no tenesmus. 

The autopsy showed a pseudo-membranous inflammation through the whole- 
length of the colon, most marked in the lower third. The other organs were normal. 
The microscopic examination of the colon confirmed the diagnosis of pseudo-membra- 
nous colitis. 

Fig. 176 shows a microscopic section of another case of pseudo-mem- 
branous colitis. 

A girl, four years old, had always been delicate. She had pneumonia twice in her 
fourth year. Eight days before her death she was attacked with vomiting and diarrhoea. 
There was blood in the faecal discharges. The pulse was rapid. The loss of strength, 
and the pallor were marked. The eyes were sunken, and the tongue was dry. On the 
last day of her life she became very feeble, and died in convulsions. Early in the dis- 
ease the discharges were frequent. Later, they were from four to six daily, and were 
accompanied by tenesmus and tenderness of the abdomen. 

The autopsy showed that the mesenteric lymph-follicles were not much enlarged ; 
the follicles in the colon were slightly enlarged. The whole intestine was injected in. 
patches, and contained faecal masses of a yellowish color. The large intestine was 
filled with large quantities of faeces of foul odor and colored by bismuth. The whole 
surface was rough, and did not look like a mucous membrane, but rather as though a. 
thin layer of gelatin had been poured over it. This film could be pulled away with 
the forceps. The solitary follicles were enlarged. The microscopic section of this 
specimen showed a marked fibrino-purulent exudation, forming a membrane which 
characterized the disease as pseudo-membranous colitis. 

In connection with the pseudo-membranous condition shown in Fig.. 
175, another specimen (Fig. 177) is of interest. 



DISEASES OF THE INTESTINE. 829 

This specimen was taken from a child, three and a half years old, who first had 
whooping-cough and was then attacked with diphtheria. During the course of the dis- 
ease the temperature was raised continuously, at times being as high as 40° C. (104° 
F.). During this attack it had diarrhoea with blood in the discharges, but no pain or 
tenesmus and no other symptoms of colitis. 

The autopsy showed a broncho-pneumonia, and a normal condition of the stomach 
and small intestine. The colon showed an apparent exudation, which simulated that 
of a pseudo-membranous colitis so closely that before the microscopic examination was 
made it was supposed to be identical with the pathological lesions found in the case of 
pseudo-membranous colitis (Fig. 175). The surface appearance in the fresh specimen 
was identical. Under the microscope, however, the lesion proved to be only a super- 
ficial necrosis of the mucosa, with swelling of the lymph-follicles. 

This case should impress upon us how important it is not to rely upon the macro- 
scopic appearances of intestinal lesions without the corroboration of a microscopic 
examination. 



ANIMAL PARASITES. 

The animal parasites which are found in the intestines of infants and 
children are the same as those which occur in older patients. The only 
ones, however, which are common and important enough to speak of are 
the oxyuris vermicularis (pin-worm), the ascaris lumbricoides (round-worm), 
the tcenia solium, and the tcenia mediocanellata (tapeworms). 

Oxyuris Vermicularis. — The oxyuris vermicularis is a minute worm, 
which looks like a little piece of white thread. The female is from 0.6 to 
1.2 cm. (I to \ inch) in length. The male is about one-third as large, 
and has the tail rolled into a spiral. Their development takes place in 
the large intestine, and the mature worms deposit their eggs in the rec- 
tum. They enter the intestine through the mouth, and children are very 
apt to reinfect themselves by carrying the eggs on the fingers or under 
the nails to their mouths. 

These worms sometimes exist in large numbers, and their development 
is so rapid that it is often difficult to dislodge them completely. The 
most common symptom of the oxyuris is an intense itching about the 
anus. The sleep of the child is disturbed by this irritation, and various 
nervous symptoms develop in children who are infested with this para- 
site. Thus incontinence of urine sometimes results. In girls the parasite, 
by migrating from the anus to the vulva, may cause a vulvo-vaginitis. 

Diagnosis. — The diagnosis of the presence of these, as of other intes- 
tinal parasites, can be made only by finding the worm or its ova in the 
intestinal discharges. When they are suspected, an enema of clear water 
should be given. If the parasites are present, they will be dislodged, 
and careful inspection will disclose their presence. Whenever there are 
symptoms of reflex irritation in the neighborhood of the anus or the 
genital organs, the oxyuris should be suspected and sought for. The 
parasites can often be found in the faecal discharges, and in some cases 
they can be seen by simply stretching open the anus and examining the 
mucous membrane of the rectum. 



830 PEDIATRICS. 

Treatment. — Although most of the worms are in the rectum, yet they 
also infest the upper parts of the intestine, and therefore cannot be reached 
by enemata. In many cases enemata of salt-and-water are sufficient to 
produce a cure, but in some cases the salt, even in small amount, is so 



Fig 




Oxyuris vermicularis. Ascaris lumbricoides. 

irritating that it cannot be used. Infusions of quassia may also be em- 
ployed as enemata. One of the most effective methods of dislodging the 
parasite is to give every evening at bedtime an injection of 60 c.c. (2 
ounces) of sweet oil. This is allowed to remain in the rectum for five or 
six minutes, and a large enema of water is then used to wash out the oil, 
which usually carries with it the parasites from the lower colon and the 
rectum. Care must be taken in regard to cleanliness, so as to prevent 
reinfection. 

When this treatment is not sufficient, lozenges of santonin, 0.01 to 
0.03 gramme (J to J grain), according to the age, may be given two or 
three times daily. 

Every two or three days a cathartic, such as castor oil or calomel, 
should be given. Care must be used in giving santonin not to produce 



DISEASES OF THE INTESTINE. 831 

symptoms of poisoning, such as gastro-enteric irritation, dizziness, and 
yellow vision. This occurrence, however, will not be common if in each 
case the effect of the drug on the child is carefully watched. Serious 
symptoms, such as convulsions, have been caused by a lack of care in 
using this drug in young children. 

Under this treatment, aided by high rectal injections, the worms can 
in most instances be eradicated. I have, however, met with very intrac- 
table cases in which months and even years had elapsed before treatment 
of any kind was successful. In such cases temporary relief can be obtained 
by giving the child each night, or two or three times a week, a small 
enema of oil. 

Ascaris Lumbricoides. — The ascaris lumbricoides is a long, cylin- 
drical, yellowish-white or reddish-yellow worm, pointed at both extremi- 
ties. The male is distinguished from the female by the fact that it is 
smaller and is always rolled upon itself, while the female is straight. The 
length of the male is from 10.4 to 18 cm. (4 to 7 inches), and that of the 
female from 15.5 to 28.5 cm. (6 to 11 inches). The eggs of this worm are 
oval in shape, 0.075 mm. long and 0.058 mm. wide. When they are first 
passed they are almost transparent, but they soon become yellowish and 
opaque. These eggs are not developed within the intestine, but may pass 
out with the faeces. They are very tenacious of life, and may develop 
under favorable circumstances after many years. The embryos are de- 
veloped outside of the body, and reach the intestine with the drinking- 
water, where they develop into the mature worm. 

The habitat of the worm is usually in the small intestine. It may, 
however, pass through the rectum either with the faeces or alone, and 
may migrate into the stomach, oesophagus, or nose. Sudden death has 
resulted from the entrance of these worms into the air-passages. They 
may also at times enter the common and cystic bile-ducts, and they have 
even penetrated farther and caused abscess of the liver. There is no 
danger of their perforating a normal intestine, but when ulceration has 
been present perforation has occurred. 

Symptoms. — There are no especial symptoms produced by this worm, 
and we can diagnosticate its presence only by seeing it or by finding the 
eggs in the faecal discharges. The worm may in some instances produce 
a feeling of discomfort or even colic in the region of the umbilicus. 
Neither of these symptoms, however, can be depended upon, and an 
anthelmintic is required to determine whether the parasite is present. In 
certain cases convulsions in children have been followed by the passage 
of a lumbricoid worm. This, however, cannot be accepted as conclusive 
evidence that the convulsion was dependent upon the worm, as I have 
met with instances in which large numbers of these worms were found at 
the autopsy in children who during life showed no nervous symptoms 
whatever. As a rule, the presence of these parasites in the intestine, 
unless in very large numbers, is not especially important. 



832 PEDIATRICS. 

Treatment. — The most efficacious treatment of this form of parasite 
is in the form of santonin, which should be given in the same doses and 
with the same caution as I have already described in speaking of the 
treatment of the oxyuris. Instead of santonin, the freshly prepared fluid 
extract of spigelia and senna in doses of 1.87 c.c. (J drachm) for a child 
two years old, and 3.75 c.c. (1 drachm) for older children, can be given 
two or three times a day, care being taken not to produce too much irri- 
tation. The oil of chenopodium, 0.012 to 0.018 c.c. (2 to 3 minims), on 
sugar, for a child two or three years old, and 0.50 to 0.60 c.c, (8 or 10 
minims) for older children, can also be given. A cathartic should be used 
in connection with these drugs, as well as with santonin. 

Taeniae (tapeworms). — Two forms of taenia occur in children. One 
of these is the tcenia solium, the pork tapeworm. It has a slight projec- 
tion at the apex of its head, around which are a series of hooks, and below 
which are four sucking-disks. The other form is the tcenia mediocanellata, 
the beef tapeworm. It has a blunter hook than the taenia solium, and 
does not have the circle of hooks. These worms vary in length from 605 
to 1512.5 cm. (20 to 50 feet). There is nothing especial to be said con- 
cerning these worms, and I refer to them merely because at times they 
occur in early life. They are never met with in nursing children when 
breast-milk forms the exclusive diet. There is reason to suppose that 
raw-beef juice may carry the eggs of the taenia. There are no especial 
symptoms produced by this worm, and the diagnosis is made entirely by 
finding the segments in the faeces. There is no especial danger from the 
presence of the tapeworm. 

Treatment. — The treatment employed for expelling this worm is the 
same in children as in adults, but we should be very careful not to irritate 
too much the sensitive gastro-enteric mucous membrane of the young child. 
The child should first be treated with laxatives, so as to free the intestine. 
Food should be withheld from the early evening until as late as possible 
the next day. An anthelmintic should then be given, followed in one or 
two hours by a cathartic. This usually results in the expulsion of a large 
mass of segments. Great care should be taken to prevent the head from 
breaking off before it is expelled. If the head remains, the worm grows 
again and the treatment has been useless. The anus should be carefully 
dilated during the expulsion of the worm. Sitting on a vessel of hot 
water seems to help to prevent the head from breaking off. 

There is no anthelmintic which I have found especially successful in 
expelling the taeniae. One of the most harmless is the alkaloid pelletierine 
from pomegranate. The tannate of pelletierine can be given to a child 
from three to five years old in the dose of from 0.01 to 0.03 gramme 
(i to J grain). As dizziness and headache are sometimes complained of, 
it is well to have the child kept in bed and lying down until the effect of 
the anthelmintic has passed off. The oleoresin of male fern may also be 
used. The dose is 0.94 to 1.88 gramme (£ to J drachm). The cathartic 






DISEASES OF THE INTESTINE. 833 

which is most useful in these cases is Epsom salt, 7.5 to 15 grammes 
(2 to 4 drachms). 

It is hardly worth while to mention the other numerous anthelmintics 
which have been recommended, as they are usually inefficient. 

Fig. 179. 




Taenia. L, without head ; IT., with head. 



If the head of the worm is not obtained and if a considerable portion 
of the segments is discharged as a result of the treatment, it is desirable 
to wait a few months before making a second attempt to dispel the para- 
site. The reappearance of segments in the stools indicates that the growth 
of the worm is sufficient to justify another attempt to dislodge it. 



DIVISION XIII. 

DISEASES OF THE LIVER, PANCREAS, SPLEEN, AND 

PERITONEUM. 



DISEASES OF THE LIVER. 

The size of the liver is in infancy very large relatively, and in early 
childhood somewhat larger than at a later period of life. This is of 
importance in making a diagnosis as to the increase or decrease of the 
normal hepatic area. These changes, although varying so much at dif- 
ferent ages from infancy to puberty, yet in the intermediate extremes of 
size show such slight differences that nothing definite can be stated in 
regard to them. In early life, however, we may say that the edge of the 
liver may be felt about 1.5 to 2 cm. (J to § inch) below the edge of the 
ribs in front, and that the hepatic dulness extends up to the fifth inter- 
space or rib in front, to the seventh interspace in the axillary line, and to 
the ninth space or rib behind. 

The left lobe of the liver is relatively larger in the child than in the 
adult. (Steffen.) In determining, however, whether or not the liver is 
of abnormal size we must consider that a downward displacement of a 
normal liver may take place from relaxation of the ligaments and of the 
abdominal walls in cases of wasting disease, also from pressure, as from a 
pleuritic effusion or from thoracic deformity as in rhachitis. Upward dis- 
placement also may take place from ascites and other causes of abdominal 
distention. 

Diseases of the liver are not common in infancy and childhood, as the 
inciting causes of hepatic disease are usually not present in early life. 
When hepatic disease is present, it is commonly secondary to some gen- 
eral disease. 

Congenital malpositions and malformations of the liver may occur, but 
those of especial clinical interest are chiefly connected with the bile-ducts, 
and have been described on page 308. 

The acquired pathological lesions which occur in the liver in infancy 
and childhood do not differ from those which are met with in later life. 
A rapid increase and decrease in the size of the liver are not infrequently 
met with in disease, and careful measurements have shown that even a 

834 



DISEASES OF THE LIVER. 835 



very slight disturbance of health may cause in young children a variation 
of from 2 to 4 cm. (f to lj inches) in the size of the liver. 

In most diseases which are accompanied by hepatic disturbance, it is 
much more common to have the liver enlarged than diminished in size. 

ICTERUS. 
Icterus is a symptom of a number of diseases, as well as of disease 
of the liver, but it so commonly occurs when the liver is either directly 
or indirectly affected that it is best spoken of in connection with hepatic 
disease. The icterus which arises at birth, either of the temporary form, 
such as icterus neonatorum, or from obliteration of the bile-ducts, has 
already been described on page 308. but it may be added to what was 
said regarding the former that there is some reason to suppose that it may 
be caused by the ductus venosus remaining patent at birth. Icterus as a 
symptom of acute and chronic duodenal indigestion has been described on 
page 799. It must not be assumed that there is necessarily hepatic dis- 
ease because icterus is present, as any slight mechanical disturbance in the 
liver produced by diseased conditions elsewhere may cause icterus. In 
these cases, even though the liver may be somewhat enlarged, it is not a 
symptom of much import, and the liver is soon restored to its normal 
condition, provided that the original disease has disappeared or has ceased 
to produce hepatic disturbance. In addition to this obstructive class of 
cases, icterus may also occur as a symptom in septic inflammation of 
the umbilical vein. In these cases the liver is apt to be enlarged and 
tender. Convulsions commonly occur. Vomiting, diarrhoea, abdominal 
swelling, pain, and tenderness are present. The temperature is high. 
The respirations are increased, and death usually occurs from exhaustion 
or from septic inflammation of the pleura, pericardium, or other parts. 

ACUTE YELLOW ATROPHY OP THE LIVER. 
It is uncommon for the liver to be decreased in size, but this occurs in 
the very rare cases of acute yellow atrophy at times met with in children. 
The disease is insidious in its onset, and is characterized by general symp- 
toms of malaise, with icterus and urine containing bile. In the beginning 
of the disease the liver is enlarged, but in the later stages it is decidedly 
diminished. Cerebral symptoms and vomiting are quite prominent, and 
death in variably occurs. 

CONGESTION OP THE LIVER. 

Although an acute congestion of the liver may occur, as from certain 
poisons and in the course of malaria, yet by far the most common form is 
the subacute or chronic condition which results from stasis in the venous 
system, produced by cardiac disease and certain pulmonary conditions 
which interfere with the circulation. 

There are no especial hepatic symptoms beyond enlargement of the 



836 PEDIATRICS. 

organ, and the treatment is that of the primary disease. This enlargement 
may occur from a number of causes, among which is mechanical congestion, 
arising in the course of cardiac disease. 

FATTY INFILTRATION OF THE LIVER. 

Fatty liver in early life is quite common, especially in infants, and does 
not differ pathologically from that which is met with at a later period. 
The liver may or may not be enlarged, and there are no especial hepatic 
symptoms, such as icterus or ascites, which characterize this condition, the 
symptoms being those of the general disease from which the child is suf- 
fering. It may be found associated with a number of diseases, especially 
rhachitis, tuberculosis, and wasting diseases, especially with those which 
are associated with disturbances of digestion. When the liver is enlarged 
from this cause its surface is found to be smooth and there is no pain nor 
tenderness on palpation. 

The prognosis, unless the disease is dependent upon some incurable 
disease elsewhere, is fairly good. 

The treatment is essentially dietetic, hygienic, and that of the original 
disease. 

SUPPURATIVE HEP ATITTS.— ABSCESS OF THE LIVER. 

Abscess of the liver is an exceedingly rare condition in both infants 
and children. Even when septic infection of the umbilical vessels has 
taken place at birth, it has been found that only in a very small propor- 
tion of these cases has hepatic abscess resulted. 

Etiology. — According to Musser's analysis of thirty-four reported 
cases, the average age was nine years, and the youngest one year. The 
causes in these cases were from traumatism, from round-worms entering 
the bile-ducts, from pylephlebitis in four cases, from umbilical phlebitis 
once, from pyaemia twice, and once each from pelvic peritonitis, dysentery, 
perityphlitis, malaria, and tuberculosis of the lungs. Musser therefore con- 
cludes that the general conditions, such as climate and habits of life, which 
are marked etiological factors in adults, are not of significance in children. 

Symptoms. — The onset, the progress, and the duration of the disease 
depend greatly on the primary cause. Icterus may occur, but usually is 
not marked, and is not of much significance. The local symptoms con- 
nected with the liver are the same as in adult life, and are chiefly pain, 
not always, however, in the hepatic region, but in different parts of the 
abdomen, enlargement of the liver, usually downward, and tenderness 
over the liver. If in addition to these symptoms a tumor is detected 
apparently connected with the liver, and accompanied by fever of a hectic, 
pyeemic, or intermittent type, with sometimes an initial chill or with 
irregular daily chills, abscess of the liver is to be strongly suspected. 
Leucocytosis is present. The symptoms are at times, however, very 
latent, and the diagnosis can only be determined by aspiration. 



DISEASES OF THE LIVER. 837 

The duration of the disease is apt to be prolonged, and the child 
gradually emaciates and fails in strength. 

The prognosis varies greatly, as there are so many conditions as to the 
especial cause and the especial locality of the abscess which must be taken 
into account and which render the chances of recovery more or less un- 
certain. 

Treatment. — The treatment is essentially surgical. Musser reports 
twelve recoveries out of the thirty-four cases, and in eleven of these 
aspiration or incision or both were employed. 

HYDATIDS.— BILIARY CALCULI.— NEW GROWTHS. 
Echinococcus cysts and biliary calculi are so rare in early life that they 
need merely be mentioned as of possible occurrence. Carcinoma, ade- 
noma, and sarcoma of the liver have in rare instances been met with 
in early life. Tuberculosis of the liver has been described on page 431. 

AMYLOID LIVER. 

When amyloid changes are present in the liver, other organs, such as 
the spleen, kidneys, and intestine, are involved. Amyloid infiltration may 
occur in the course of tuberculosis when there is chronic disease of the 
bones with extensive suppuration, in wasting diseases, and in hereditary 
syphilis. A very prominent symptom in this condition is an extreme degree 
of secondary anaemia. The liver is, as a rule, very much enlarged, and 
commonly more so than in any of the other hepatic disturbances. Its 
surface is smooth, and there is rarely hepatic tenderness or pain. Ascites 
is rare, and there is usually no icterus. The progress of the disease is 
slow. 

The diagnosis is not difficult if we find that the child has one of the 
diseases which have just been mentioned as being the causes of amyloid 
changes. The skin has a waxy appearance. The spleen is enlarged, 
and there may be albuminuria and dropsy, either from an associated 
amyloid condition of the kidney or from the pressure produced by the 
enlarged liver. 

When these changes occur in the liver the prognosis is very grave, 
and there is no treatment which will be of more than temporary benefit. 
The treatment, therefore, is removal, if possible, of the cause, such as a 
diseased joint. If the disease is the result of syphilis, anti-syphilitic 
remedies should be employed. 

Fig. 180 represents a boy seven and three-quarter years old. There was no his- 
tory of tuberculosis in his family. He had pertussis when he was one and a quarter 
years old, and measles when he was three years old. He seemed well and strong until 
he was about seven years old, when he became listless and began to have fever and to 
perspire profusely. Later he began to vomit occasionally, to complain of headache, 
and to cough. Although he evidently lost in weight he was not especially emaciated. 
His entire skin was extremely pale and had a waxy look, Avhich was apparently not 



PEDIATRICS. 



due to jaundice. His mucous membranes showed much anaemia. His tongue was 
heavily coated, and his breath was offensive. He was dull and apathetic. The cer- 
vical glands were enlarged and slightly tender, but did not fluctuate. The glands were 
moderately enlarged in the axilla? and groins. The percussion of the right lung, espe- 
cially at the apex, was dull, and there were numerous rales. The area of cardiac dul- 
ness was not enlarged, but there was a slight systolic murmur at the apex. The spleen 



Fig. 180 




Amyloid liver. Pulmonary tuberculosis. Male, 7% years ol 



was slightly enlarged. The edge of the liver could be felt below the line of the um- 
bilicus. The area of hepatic dulness was increased, as is represented by the broken line 
in the figure. There was no hepatic tenderness, and the child did not complain of 
pain. The lower part of the abdomen was dull on percussion as high as the line which 
is drawn under the umbilicus. This was due to a slight amount of ascites. The legs 
were swollen. The urine had a specific gravity of 1010, and contained a slight trace 
of albumin, an occasional hyaline cast, and renal epithelium. The temperature had 
varied from 37.2° to 39.4° and 40.5° C. (99° to 103° and 105° F.). The increased 
size of the liver was probably due to amyloid infiltration, following what was supposed 
to be pulmonary tuberculosis. 

A few days later the child grew rapidly weaker, and died of exhaustion. An 
autopsy was not obtained. 



INTERSTITIAL HEPATITIS.— CIRRHOSIS. 

Interstitial hepatitis may be a lesion of a number of systemic diseases, 
especially of syphilis, but also of tuberculosis. The disease, however, 
may apparently occur without disease of any other organ. In infants 
cirrhosis of the liver is almost invariably of syphilitic origin. 

A certain number of cases seem to have followed scarlet fever and 
measles. Alcohol is sometimes an etiological factor in infancy and early 
childhood. When the disease is caused by alcohol the pathological condi- 
tion is, as a rule, atrophy. 

Interstitial hepatitis as it occurs in childhood may be atrophic or hyper- 
trophic The general symptomatology differs but little from that of the 



DISEASES OF THE LIVER. 



839 



adult. In the beginning the symptoms are very apt to be confounded with 
those of simple congestion arising from digestive disturbances. There 
may be abdominal pain, slightly augmented by pressure. Diarrhoea and 
constipation alternate. There are usually ascites and slight jaundice, and 
at times dilatation of the subcutaneous abdominal veins. Stigmata com- 
posed of collections of dilated minute veins are sometimes observed on 
the face. The temperature is irregular. As a rule, it is not much height- 
ened, and, in fact, is often subnormal. 

Enlargement is not common, and the symptoms are the same as in the 
adult, the ascites being especially prominent. 

Prognosis. — The prognosis in this class of cases is bad, as the progress 
of the disease is usually rather rapid. 

When the hepatitis is not dependent on disease elsewhere, and is not 
due to alcohol, there are no characteristic symptoms beyond the enlarge- 
ment of the liver. In this form the ascites is usually small in amount, and 
the diagnosis can be made only by eliminating the other forms of enlarge- 
ment. It is commonly spoken of as hypertrophic cirrhosis. Its prognosis 
is more favorable than that of the cirrhosis just described. Its treatment 

is symptomatic. 

Fig. 181. 




Hypertrophic cirrhosis. Female, 18 months old. 



Fig. 181 represents a girl eighteen months old. There was no history of syphilis 
or of tuberculosis. She had pertussis when she was ten months old, and the cough 
lasted for several months. She had never been given alcohol in any form. She was 
well until she was fifteen months old, when she began to complain of pain in the 



840 PEDIATRICS. 

abdomen and to become pale. Before entering the hospital she had diarrhoea, and 
her abdomen was swollen. On entering the hospital and being placed on a proper 
diet, the diarrhoea ceased, but the swelling of the abdomen increased. She was not 
especially thin, but was pale. The abdomen was much enlarged. The edge of the 
liver could be felt nearly as low as the line of the umbilicus. The area of dulness on 
percussion is marked by black lines. The lower one shows the notch between the 
right and the left lobe, which was distinct and easily palpable. There was no especial 
tenderness on pressure. The spleen was slightly enlarged. In the lower part of the 
abdomen there was a moderate amount of dulness and fluctuation, showing the pres- 
ence of fluid. There were no glandular swellings. The heart was normal, but was 
pushed up somewhat by the abdominal distention. 

The child improved in its general health while in the hospital, and had a fair appe- 
tite. Physical examination showed the presence of no other disease. Without an 
autopsy, however, the diagnosis was necessarily held in abeyance. 

The child remained in the hospital for a few weeks, and improved in its general 
health so that it seemed quite bright. The ascites did not increase in amount, but the 
liver remained enlarged. The child was eventually taken away from the hospital, and 
its subsequent history could not be obtained. 

DISEASES OF THE PANCREAS. 
Diseases of the pancreas are practically unknown in infancy and child- 
hood, with the exception of the general tissue-changes which may be met 
with in syphilis, and which have already been described. New growths 
of a malignant nature have been reported. 

DISEASES OF THE SPLEEN. 

The spleen may be involved in tuberculosis, and may show amyloid 
changes in connection with other organs. It is frequently enlarged in the 
course of a number of diseases which have been described elsewhere, but 
there are no primary diseases of the spleen. 



DISEASES OF THE PERITONEUM. 

Diseases of the peritoneum may be of non-inflammatory or inflamma- 
tory origin. 

The non-inflammatory diseases are mostly represented by new growths. 
These may be of a malignant nature, such as carcinoma and sarcoma, or 
they may be lipomata or of a cystic character. Tumors of the omentum 
are rare, but cysts and hydatids may occur in this region. The differen- 
tial diagnosis of these various forms of peritoneal and omental growths 
can scarcely be made during life. The treatment is essentially surgical. 

The inflammatory diseases of the peritoneum are represented by peri- 
tonitis. 

ACUTE PERITONITIS. 

Etiology. — Acute inflammation of the peritoneum may be primary or 

secondary. It is a condition of great importance in infancy and early life. 

Infants and children of any age may be attacked. The disease may 



DISEASES OF THE PERITONEUM. 841 

occur in the course of tuberculosis, of the infectious diseases, of syphilis, 
and. most frequently of all. of appendicitis. The disease in any of the 
above forms is exceedingly rare between the ages of six weeks and two 
years. 

A large variety of micro-organisms are found in connection with acute 
peritonitis. The colon bacillus is the most frequent cause. Streptococci, 
staphylococci, and pneumococci are sometimes found either alone or in 
mixed cultures. In the rare instances of perforation of typhoid ulcers 
typhoid bacilli may be cultivated from the abdominal fluid in conjunction 
with the colon bacillus and other intestinal micro-organisms. Tubercular 
peritonitis has been described on page 401. 

Perforation of some viscus into the peritoneal cavity is the underlying 
cause of many cases of peritonitis. Such an accident may occur from 
intestinal ulcers, from abscesses and cysts of the liver, gall-bladder, spleen, 
kidney, lymph-glands, and appendix, and from strangulated hernias and 
intussusceptions. 

Peritonitis may also be set up by extension from neighboring inflamma- 
tory processes, even when no direct communication has been made with 
the peritoneal cavity by means of perforation. 

Traumatic peritonitis may develop from blows, punctured wounds, and 
septic infection from surgical operations. 

Pathology. — The pathological lesions in acute peritonitis are repre- 
sented by reddening and loss of the normal glistening appearance of the 
peritoneum, soon followed by an exudation varying from a thin serum 
with a small number of white and red blood-corpuscles to a thick, fibrino- 
purulent exudate. The character of the pathological processes have 
been more fully described under the various forms of appendicitis with 
peritonitis on page 815. In the peritonitis of the new-born the charac- 
teristic lesions are apt to be in the umbilical region, and are not infre- 
quently associated with lesions of a general septicaemia. 

Symptoms. — The symptoms of acute peritonitis vary according as the 
process is general or localized. The localized form of peritonitis corre- 
sponds in its symptoms to what has already been described in speaking 
of appendicitis, which is its most frequent cause. In general peritonitis 
the symptoms in infants are often obscure. In children the symptoms 
are usually pronounced and characteristic. The child is attacked with 
abdominal pain and with general abdominal tenderness. The abdomen 
becomes distended and tympanitic, and the child assumes the position 
which will most relax the abdominal walls, — that is, with the thighs flexed 
and the knees bent. Vomiting is very apt to be present, and is augmented 
when food is given. The bowels are often constipated, although at times 
there may be diarrhoea. The temperature is usually high, 38.3° to 40.5° 
C. (101° to 105° F.) : in some cases, however, the temperature may be 
normal or subnormal. The pulse is small and rapid. The respirations 
are not only accelerated, but also superficial, as deep respiration causes 



842 PEDIATRICS. 

pain. The face has an anxious expression, and shows great suffering. 
When recovery takes place, these symptoms gradually subside after a few 
days, the tenderness, pain, and tympanites disappear, and the child's face 
assumes a tranquil look. When improvement does not take place, the 
pulse becomes weaker and more rapid, the breathing more superficial 
and more frequent, there is chilling of the extremities, and the child dies 
usually within a week. Leucocytosis is generally marked unless the 
severity of the infection is so great as to render a reaction impossible. 

Peritonitis of the New-Born. — This form generally appears within the 
first two or three days of life, rarely later than the first week. The onset 
is sudden, with vomiting, diarrhoea, pain, distention of the abdomen, and 
tenderness. The temperature is very high, 40° C. to 41° C. (104° F. to 
106° F.). In a case reported by Quinquand it reached 42.5° C. (108.5° 
F.). Emaciation is rapid and the cachexia is extreme. Hydrocele, gen- 
erally of the right side, with oedema of the scrotum, frequently develops. 
Septicaemia and pyaemia may occur as complications. Death takes place 
in four or five days. 

Acute Pneuniococcus Peritonitis. — Peritonitis may be due to a 
primary idiopathic infection by the pneuniococcus, or to a secondary in- 
fection from the same organism in connection with pneumonia, pleurisy, 
or meningitis. Netter has reported a case of pneuniococcus meningitis 
with pneumococcus peritonitis in an infant three or four days old. Accord- 
ing to Comby, primary pneumococcus peritonitis is more frequent in chil- 
dren than in adults, and is most common between the ages of three and 
twelve years. In Brun's series of cases it Avas nearly four times more 
frequent in girls than in boys. 

Dieulafoy describes pneumococcus peritonitis as a special clinical 
form, which can sometimes be diagnosticated by the character of the 
symptoms. 

Symptoms. — The onset is sudden, with intense abdominal pain, diar- 
rhoea, and faecal vomiting. The temperature rises to 39° to 40° C. (102.2° 
to 104° F.), and there may be delirium. A remission of some of these 
symptoms then ensues, the pain subsides, diarrhoea and distention per- 
sist, and the picture is more like that of typhoid fever. At the end of 
about eight days the temperature falls, sometimes as abruptly as in 
pneumococcus pneumonia. The disease then passes into another stage, 
which resembles tubercular peritonitis. There is emaciation, cachexia, 
pinched features, sunken eyes, and a large and tender abdomen, usually 
with signs of fluid. The fluid, which is purulent, is not very movable, but 
shows a strong tendency to become encysted. The process may go on 
for several weeks and finally end in spontaneous evacuation of the pus. 
While recovery may take place by natural means, the danger of secondary 
infection and death from exhaustion is so great that early surgical inter- 
ference is indicated, as under favorable conditions a good proportion of 
the operative cases recover. 



DISEASES OF THE PERITONEUM. 843 

Prognosis. — The prognosis in acute peritonitis is always grave. It de- 
pends largely upon the virulence of the exciting cause, upon an early 
diagnosis, and upon prompt and skilful surgical treatment. 

Treatment. — The treatment is essentially the same as has been de- 
scribed under appendicitis with peritonitis on page 819. 

The following case illustrates acute peritonitis : 

An infant, nineteen months old. previously apparently healthy, was attacked with 
vomiting and diarrhoea. On the following day the face was pale, the alse nasi were 
working slightly, the respirations were 36, and the temperature was 39.4° C. (103° F.). 
The respirations gradually increased to 74, and the temperature rose to 40.3° C. (104.6° 
F.). The abdomen became very much distended and tender, and the face pinched 
and anxious. On the evening of the second day from the onset of the disease the 
temperature rose to 41.1° C. (106° F.). the infant became very restless, the pupils 
were contracted, and death took place a few hours later. 

The autopsy showed that the heart and lungs were normal. The spleen was en- 
larged, and was covered with a fibrinous exudation. The kidneys were pale, and normal 
in size. The liver was covered with flakes of lymph of recent formation, and on sec- 
tion showed the acini to be red and their periphery yellowish and opaque. The mes- 
enteric lymph-nodes were slightly enlarged, and the smaller ones were translucent on 
section and presented evidence of hyperplasia. A small pocket of the larger nodes 
was found to have become cheesy in the central portions, and in two of these the pro- 
cess had extended through the substance of the gland and had broken through its peri- 
toneal covering. About these points of rupture there was a small zone of reactive 
inflammation. 

The pathological diagnosis was acute general peritonitis, which, from an absence 
of any other source, must be considered to have been caused by the rupture of the 
cheesy, degenerated mesenteric nodes. 

In this case the high temperature and the distended abdomen rendered the diag- 
nosis comparatively clear. The case is important on account of the cause, for there 
is seldom any noticeable enlargement of the mesenteric nodes under the age of three 
years, and these nodes seldom soften, but either retrograde or harden from calcification. 

CHRONIC PERITONITIS. 

By far the most common cause for chronic peritonitis with ascites is 
tuberculosis, which has been described on page 401. 

When an acute peritonitis is localized, the inflammatory process may 
subside, the fibrino-purulent exudation may become organized, and the 
result be fibrous adhesions binding the coils of the intestine closely to- 
gether and to the abdominal Avail. 

A form known as congenital peritonitis occurs, but is of pathological 
rather than of clinical interest. In this form the fibrous adhesions are 
found in infants who have died within a few hours after birth. It is con- 
sidered a peritonitis of intra-uterine development, possibly through the 
placenta from an intra-uterine peritonitis in the mother. 



DIVISION XIV. 

DISEASES OF THE KIDNEYS, BLADDER, AND GENITAL 

ORGANS. 



DISEASES OF THE KIDNEYS. 
Diseases of the kidneys may be congenital or acquired. 

CONGENITAL DISEASES. 
The congenital abnormalities, such as congenital cystic kidney, absence 
of one kidney, hypertrophy of the remaining kidney when one is absent, 
anomalous shapes of the kidney, and malpositions of the ureters, are 
important, but are of surgical rather than of medical interest. The tabu- 
lated kidney, already described as a normal condition in intra-uterine life, 
may to a greater or less degree continue into infancy and childhood, but 
has no pathological significance. Movable kidneys are rare in early life, 
but have been reported. 

ACQUIRED DISEASES. 

Renal disease as a primary affection in infancy and childhood has 
been considered rare, but this view has been modified by later investi- 
gations, which have shown that nephritis is not uncommon in cases of 
general infection. Secondary renal lesions are comparatively common. 

The systematic examination of the urine in children in connection 
with the different pathological lesions of the kidney has not yet been 
made to such an extent that we can invariably differentiate the especial 
type of lesion by the character of the urine. Clinically, the diseases of 
the kidney, as differentiated by the urinary examination in infancy and 
early childhood, are less varied than in adults. They are represented 
chiefly by active hyperemia and the mild and severe forms of acute 
nephritis following scarlet fever especially and other of the acute infectious 
diseases. 

General Etiology and Pathology. — According to Councilman, to whom 
I am indebted for much information on this subject, the acquired diseases 
of the kidney in childhood show considerable differences from the renal 
diseases of the adult. In childhood there is a greater liability to those 
acute affections, such as scarlet fever, measles, and diphtheria, in the 

844 



DISEASES OF THE KIDNEYS. 845 

course of which nephritis is apt to appear. Children under the age of fifteen 
years are less subject to many pathological conditions, such as disorders 
of the circulation, which in the adult frequently lead to chronic lesions 
of the kidney. Children do not usually have those disorders of the 
circulation which result in granular kidney, for lesions of the arteries, 
especially the condition known as arterio-sclerosis, do not commonly 
occur in childhood. While it is true that typical examples of the small 
granular kidney are sometimes met with in children, these lesions of the 
kidney are primary, and the lesions of the circulatory system are 
secondary and dependent on the renal lesions. A part of the chronic 
diseases of the kidney in the adult is without doubt to be referred to the 
continuous action on the kidney of slight pathological conditions, an 
action from which the child's age protects it. One pathological lesion 
not perfectly recovered from, moreover, makes the kidney more prone to 
disease, and a greater effect will be produced a second time by the same 
cause, and chronic disease may result. In the kidney of the adult, with 
the advance of years there is a gradual decline in the power of regen- 
eration, and slight troubles are not readily recovered from. The kidney 
of the child, on the other hand, is an organ which possesses great power 
of growth and regeneration. For this reason a condition which in the 
adult organ is either not recovered from at all, or lays the foundation for 
chronic disease, may in childhood result in complete recovery. Again, the 
child is not exposed to certain conditions which are productive of chronic 
lesions, or which may lay the foundation for them. Among these may be 
mentioned alcoholism and excesses of various sorts. Many cases of 
nephritis in the adult are to be referred to causes acting not through the 
blood, but through the urinary tract. The child, on the other hand, is not 
exposed to the dangers arising from hydronephrosis and pyelonephritis, 
except to a very limited degree. Although the causes of renal disease 
are less numerous and less common in children than in adults, yet when 
the same etiological factor is present the same morbid condition is pro- 
duced in the kidney. The various cachectic conditions will lead to amy- 
loid infiltration in the child as they do in the adult, and amyloid in- 
filtration of the kidney makes up by far the larger part of the chronic 
cases of albuminuria in children. We may also meet with certain chronic 
lesions in the child's kidney, such as are seen in tuberculosis, and these 
may lead to albuminuria and to nephritis. 

The acute diseases of the kidney may either lead to recovery or may 
of themselves prove fatal. They are not to be referred to the contin- 
uous action of the poison of the acute disease, but to the effect on the 
kidney of the lesions produced by the inflammatory process. An example 
of this is the condition of chronic nephritis after scarlet fever, in which the 
acute lesions gradually pass into the chronic. These chronic lesions are 
to be attributed to the disorders in the circulation of the organ brought 
about by the destruction of the glomeruli. 



846 PEDIATRICS. 

General Symptomatology. — The general symptoms connected with the 
various forms of nephritis are so similar that it will be less confusing to 
mention first the common symptoms which may occur in any of the 
forms of nephritis, and then to describe the etiology, pathology, and 
urinary examination of the different forms. 

One of the most common signs in nephritis is oedema, which occurs 
frequently in acute nephritis and in chronic parenchymatous nephritis. 
The oedema generally appears first in the eyelids, and then in the hands 
and feet. There may be general anasarca. Not infrequently, however, 
oedema is absent or not marked. Nausea and vomiting are not infrequent 
in the beginning of the disease, and in some cases are, perhaps, due to 
the heightened temperature. It may occur later in the disease as a 
symptom of uraemic poisoning. In such cases there is marked diminution 
in the amount of the urine, or even suppression. A marked secondary 
anaemia giving a peculiar dull white color to the skin is commonly seen in 
chronic parenchymatous nephritis, and is quite striking. In acute 
nephritis fever is often present to a greater or less extent, but is a variable 
symptom. Lack of appetite, and weakness, are common in both acute 
and chronic nephritis. Headache is a variable symptom. It is a frequent 
symptom of uraemia, and sometimes the only one. Restlessness and 
insomnia are often met with, and attacks of dyspnoea may occur. Amau- 
rosis may occur as the result of albuminuric retinitis, or it may be a func- 
tional symptom of the uraemic poisoning and disappear later if the patient 
recovers. Hypertrophy of the left ventricle with a pulse of high tension 
is apt to occur in interstitial and chronic parenchymatous nephritis. Both 
diseases are, however, very uncommon in childhood. In acute nephritis 
following scarlet fever dilatation and moderate hypertrophy of the left 
ventricle are not uncommon. Transudation into the serous cavities 
has been reported in a number of cases, as has also oedema of the 
larynx. 

In all cases of nephritis the amount of urea excreted during the twenty- 
four hours should be carefully estimated from time to time, as a decrease 
in the urea always suggests a pathological condition, and a return to the 
normal amount is usually indicative of recovery unless there is a com- 
plication with some other disease. Any interference with metabolism, 
however, Avhether in the liver or in the lung, may diminish the amount 
of urea in the urine. In children during convalescence from acute ne- 
phritis the urea returns to or exceeds the normal amount, while in chronic 
nephritis it is always diminished, as it is in adults. A sudden and exces- 
sive diminution of the urea in acute nephritis is suggestive of uraemia. 
In acute and chronic nephritis the chlorides are diminished when an 
effusion such as ascites is increasing, and gradually return to the normal 
amount as the effusion is absorbed. 

In any attempt to estimate the functional activity of the kidney, either 
as regards the quantity of urine or the amount of solids excreted, it is 



DISEASES OF THE KIDNEYS. 847 

very desirable to know the amount passed in twenty-four hours. This is 
practically impossible in infants and very young children, in whom it is 
often difficult to obtain even a single specimen. Various methods have 
been devised for collecting the urine in infants. The most simple and 
effective is a cotton ring large enough to enclose the buttocks and genitals. 
The ring is lined with sheet rubber, and the infant (the napkin having been 
removed) rests upon it comfortably, and the urine can be collected as in 
a bed-pan. 

ANURIA. 

Anuria is an arrest of the secretion of urine. It must be distinguished 
from retention of urine in the bladder, from the scanty urine passed when 
liquids are withheld or refused in sickness, and from diminished secretion 
dependent upon a profuse watery diarrhoea. Total suppression of urine 
may occur in the intense congestion of acute nephritis, in poisoning by 
lead, phosphorus, or turpentine, or after severe injuries or operations. 

Anuria in the new-born may be due to malformation of the urinary 
tract or to uric acid infarction. Other cases in infants are evidently of 
nervous origin, and may last for twenty-four or thirty-six hours without 
other symptoms. Hysterical anuria may occur in older children. Charcot 
reports a case lasting for eleven days. 

Treatment. — The obstructive cases demand operation. In non-ob- 
structive cases the treatment is usually simple and satisfactory. Sweet 
spirits of nitre or citrate of potash given with plenty of water will usually 
relieve the condition. Hot applications over the kidney may be used, or 
large hot irrigations of the colon with salt solution, or in extreme cases 
the subcutaneous injection of salt solution. 

PHYSIOLOGICAL ALBUMINURIA. 
This condition is not infrequent, and may occur at any period of 
infancy and childhood, but is most common between the fifth year and 
puberty. It is more common in boys than in girls. The amount of albu- 
min present is, as a rule, less than one-twelfth per cent., and is sometimes 
associated with temporary glycosuria. It is not present in every micturi- 
tion, and in many cases seems to depend upon over-exercise, cold bathing, 
or a highly nitrogenous diet. The albumin is rarely present in the urine 
which is passed in the morning immediately after rising, and this is an im- 
portant point in differentiating physiological albuminuria from periodic 
albuminuria due to pathological causes, such as uric acid. The presence 
of blood-corpuscles or abnormal elements in any amount from the kidney 
shows that there is a pathological condition. The children who have 
this physiological albuminuria often seem to be in good health, but some- 
times they are rather delicate. The diagnosis can be made only by re- 
peated examinations of the urine passed at different times in the day, and 
by observing the effect of exercise and diet upon it. An occasional hya- 
line cast and albumin as high as one-fourth per cent, for short intervals 



848 PEDIATRICS. 

may be present. The albumin often disappears for a time and returns 
again. 

Albuminuria of Adolescence. — One form of physiological albumi- 
nuria is that which has been called the albuminuria of adolescence. At 
puberty there appears to be a disturbance of the equilibrium of the renal 
circulation, occurring so frequently, and presenting so distinctively the 
characteristics of a simple hyperemia, that we are justified in looking 
upon it as a physiological rather than as a pathological condition. 

This physiological congestion of the kidney is probably closely con- 
nected with the development and increased activity of the uterine circu- 
lation in the female, and with the prostatic and genital blood-supply in 
the male. The importance not only of knowing that such a condition 
exists at puberty, but also of bearing it in mind when we are called to 
treat children who are on the border-line between childhood and adoles- 
cence, is too little recognized, and this Avant of recognition often leads to 
unfortunate mistakes. 

Prognosis. — The prognosis in these cases of physiological albuminuria 
is, as a rule, good ; but although I know of no cases in which the condi- 
tion terminated in nephritis, yet the prognosis should be guarded. 

Treatment. — The treatment is to regulate the diet, exercise, and gen- 
eral hygiene carefully. If the children are anaemic, iron is indicated. 

The following is one of a number of cases of albuminuria of adoles- 
cence which have come under my notice : 

A girl, thirteen years old, was brought to me for advice with the following history. 
She had always been somewhat delicate, but had never had any especial disease, and 
was considered to be fairly healthy, until she was twelve years old. She then began 
to grow very fast in height without a corresponding development in weight and gen- 
eral muscular strength. When she was twelve and a half years old the catamenia 
appeared, and were accompanied by severe pain. Six weeks later, the catamenia again 
appeared, and were accompanied by considerable pain and general prostration. The 
child at this time looked pale and thin, had very little appetite, and was easily fatigued. 
A physician was consulted, who prescribed strong food, such as meat, a tonic, and 
gymnasium exercise. This advice was followed implicitly, and the child was made to 
exercise especially the muscles connected with the abdomen and pelvis three or four 
times a week at the gymnasium, and by daily home exercise, such as lying on the 
back and raising the legs. Under this treatment the child rapidly grew worse, and the 
catamenia did not return in the following month. 

A physical examination of the child showed nothing abnormal beyond too rapid 
growth. The total quantity of urine in twenty-four hours was 960 c.c. (32 ounces). 
The color was normal, reaction acid, specific gravity 1023, urea increased, a very slight 
trace of albumin, sugar absent. The sediment showed a considerable amount of 
mucus, a little vaginal epithelium, an occasional granular and epithelial cast, renal 
epithelium, and an occasional- blood-globule. 

The urine was simply one which showed a slight renal hyperemia, and the child 
was therefore treated as follows. She was not allowed to go to school or to the gymna- 
sium, but was made to rest in bed for several hours twice a day. Her diet was largely 
milk in considerable quantity, meat especially being withheld. She was also made to 
drink freshly distilled water, 250 c.c. (about eight ounces) once in six hours. She was 
allowed to take a slight amount of exercise out of doors, but to a very limited degree. 



DISEASES OF THE KIDNEYS. 849 

Under this course of treatment the child began slowly to improve. She became 
less anaemic ; her appetite increased, and was less capricious ; she began to gain in 
weight, to sleep well, and to have more strength. 

Subsequent examinations of the urine showed a progressive improvement until, 
at the end of one year, the albumin had entirely disappeared and the urine became 
normal. 

HEMATURIA AND HEMOGLOBINURIA. 

Haematuria is the term applied to the presence of red blood-corpuscles 
in the urine. Haemoglobinuria is the term used to describe those cases 
in which the haemoglobin or blood-pigment is present in the urine with- 
out the red blood-corpuscles themselves. Both conditions are to be con- 
sidered as symptoms of some primary disease rather than distinct dis- 
eases in themselves. Haematuria and haemoglobinuria are, as a rule, 
easily recognized by the color of the urine if sufficient blood or blood- 
pigment is present to color it. The color is red if it is due to fresh blood, 
or brownish red if due to blood-pigment which has been washed out of 
the corpuscles. 

Etiology. — Haematuria is often the first indication of an acute nephritis 
from any cause. It may also occur as a result of scorbutus, haemophilia, 
pernicious anaemia, and leukaemia. Malignant disease of the kidney, 
uric acid concretions in the kidney and bladder, and trauma, are at times 
the direct cause of the condition. 

Both haematuria and haemoglobinuria, usually in small amounts, may 
be caused by poisons, such as carbolic acid, cantharides, and chlorate of 
potash, and also by infectious diseases, such as scarlet fever, typhoid, and 
malaria. 

Paroxysmal hemoglobinuria is of rare occurrence in childhood. The 
cause is obscure. Some cases are probably of malarial origin ; many 
others seem to be dependent upon over-exertion and exposure to cold, 
such as may come from chilled or wet feet, or from a cold-water plunge. 

Symptoms. — With the onset of the attack there may be severe symp- 
toms of chills, fever, rapid and small pulse, and prostration. Again there 
may be hardly any subjective symptoms, the color of the urine alone 
being noticed. When the haematuria is dependent upon an acute ne- 
phritis, the symptoms follow the course of the primary infection. 

Diagnosis. — To determine the source and cause of the hemorrhage is 
often quite 'difficult, and at times is impossible. When the blood comes 
from the bladder it may not be uniformly diffused through the urine, and 
small clots are common. In addition to this there are symptoms of 
disturbance of the bladder, such as tenesmus and frequent and perhaps 
interrupted micturition. In hemorrhage from the kidney the blood is 
diffused through the urine. The color may be red or brownish reel. The 
microscopic examination shows epithelium and casts from the kidney, 
many of which contain red blood-corpuscles embedded in them, and are 
knoAvn as blood-casts, and the renal elements are stained yellow and 
brown from long contact with the blood. There are also normal blood- 

54 



850 PEDIATRICS. 

corpuscles, and others from which the haemoglobin has been washed out, 
which appear as pale rings, the biconcavity being lost. 

The diagnosis of hematuria rests upon the detection, by microscopic 
examination, of the red blood-corpuscles, either in a normal condition, 
or decolorized, in the urine. When these are absent and the color of 
the urine suggests the presence of blood-pigment, the haemin test by 
glacial acetic acid will show the characteristic crystals if blood-pigment is 
present. 

Infectious haemoglobin uria has been described on page 314. 

Treatment. — The treatment of haematuria and haemoglobinuria con- 
sists in that of the primary diseases. The cause should be determined, 
if possible, and the indications for treatment followed. Rest in bed and 
a milk diet until the urine is normal should be enforced. 

CHYLURIA. 

Chyluria is a rare disease. Two forms are usually spoken of, the 
tropical and the non-tropical. 

Etiology. — The tropical form is caused by a parasite, the filaria san- 
guinis hominis, a species of round-worm. This parasite is found in the 
blood during the night ; in the daytime the blood is almost or entirely free 
from them. The parasite is found at times in the urine. The exact con- 
nection between the parasite and the chyluria has not yet been deter- 
mined. In the non-tropical form the parasite has not been found. Cases 
have been reported in which the parasite appeared in an individual residing 
in the tropics, and disappeared on his returning to a cold climate, although 
the chyluria continued. The chyle is supposed to get into the urine after 
it has left the kidney. 

Symptoms. — The symptoms of this disease are shown chiefly in the 
urine. The urine has a milky appearance, sometimes a sour odor, and 
tends to decompose rapidly. The reaction is slightly acid, or neutral. 
Microscopic examination shows the fluid to be filled with fine granules or 
fat drops in suspension. The urine at times contains blood-corpuscles, 
and albumin is always present. The attacks are apt to be paroxysmal, 
lasting for days or weeks, then ceasing and again recurring. A fatty diet 
may or may not cause an increase in the chyluria. The individuals 
affected by the disease may have a healthy appearance. Co'agula may at 
times be formed in the bladder and give rise to pain and difficult micturition. 
The lymph-nodes, especially in the inguinal region, are sometimes enlarged. 

Prognosis. — The prognosis of chyluria is doubtful. It is a disease 
which lasts for a long time, and may cause anaemia and emaciation from 
the loss of fat and albumin. 

Treatment. — There is no drug known which destroys the embryos 
in the blood. In infected districts the drinking-water should be boiled. 
A diet containing little liquid and little fat will cause the chyle to dis- 
appear from the urine, but this, of course, does not constitute a cure. 



DISEASES OF THE KIDNEYS. 851 

The removal of the adult worms from the enlarged lymph-nodes by 
surgical means has been the most successful treatment. 

GLYCOSURIA. 
Glycosuria is a symptom, characterized by the transient appearance of 
sugar in the urine. It may result from poisoning with such substances as 
carbonic acid gas, morphine, or mercury, or it may appear in connection 
with acute infectious disease, such as diphtheria, scarlet fever, typhoid 
fever, or malaria. It is not infrequently dependent upon some disturb- 
ance of the nervous system resulting from a fracture of the skull, cerebro- 
spinal meningitis, or epileptiform convulsions. Glycosuria may occur in 
infants as well as in children, although usually not in those who are 
healthy. It is often associated with digestive disturbances. It may depend 
partly on the diet, and in these cases is called dietetic or alimentary gly- 
cosuria, and Koplik found glycosuria in five out of ten infants who were 
taking a food largely composed of sugar. The amount of sugar excreted 
is usually small and its appearance transient, by which the condition may 
be readily distinguished from the disease diabetes mellitus if the urine is 
examined frequently and at different times during the twenty-four hours. 

ACUTE IRRITATION. 

Etiology. — An acute irritation of the kidneys may arise in the course 
of various acute infectious diseases from the elimination of irritating solu- 
ble toxins. Fermental diarrhoeas and acute ileo-colitis are frequent causes 
of acute irritation in children. It may also be caused by an excess of 
uric acid, and by such irritating drugs as turpentine, cantharides, and 
arsenic, lead, large doses of calomel, salicylic acid, and potassium chlorate. 
Concentrated urines, and urines containing bile and sugar, also act as irri- 
tants, and lead to a hyperaemic condition of the kidneys. Irritants due to 
inflammations of the bladder from gonorrhceal and tubercular infections 
may, by extension upward along the ureters, give rise to an acute irrita- 
tion of the straight or collecting tubules. When the action of these causes 
is very intense, or when the irritation is sufficiently prolonged, the lesions 
and symptoms of acute degeneration or of the severer forms of acute 
diffuse nephritis are developed. 

Pathology.^ — The pathological conditions resulting from acute irritation 
of the kidneys are represented by degeneration and desquamation of the 
renal epithelium and injection of the blood-vessels. In many cases it is 
not to be distinguished from the lesions of acute degenerative nephritis. 

Symptoms. — Unless the irritation is very pronounced, there are, as a 
rule, no general symptoms. 

Urine. — The urine is clear, acid, and its color is often normal. If the 
irritation is due to a febrile disturbance, the urine is generally high- 
colored, concentrated, and diminished. If the cause is not febrile, the 
urine is often either normal in quantity or dilute. The amount is 



852 PEDIATRICS. 

diminished. The specific gravity is generally increased. The solids are 
either normal or slightly diminished. There is a slight sediment, with a 
slightest possible trace of albumin. Microscopic examination shows the 
presence of renal epithelium and blood-corpuscles ; the latter, however, 
are not in sufficient number to color the urine. There are also leuco- 
cytes, and hyaline and fine granular casts, with an occasional epithelial 
cast and blood cast ; the last three varieties of casts, however, are not 
very numerous. 

In the severer forms of irritation the albumin may be present in large 
traces. It is doubtful, however, whether it is important or possible to 
attempt to distinguish from the clinical signs and symptoms an acute irri- 
tation of the kidney from an acute degenerative nephritis. But if the class 
of cases above described are to be classified as a form of acute nephritis, 
it is of the utmost importance to recognize that the diagnosis of acute 
degenerative nephritis does not carry with it the serious prognosis that is 
usually associated with the term acute nephritis or acute diffuse nephritis. 

Prognosis. — The prognosis in these milder forms of irritation is good. 
Dropsy never develops, the blood and renal elements rapidly disappear 
from the urine upon removal of the cause, and the urine soon regains its 
normal condition. 

Treatment. — The child should be placed on a diet exclusively of milk, 
so as to avoid any further irritation of the kidneys, and should be made 
to drink a great deal of water. It should be kept quiet, and its general 
hygiene carefully regulated. Sweet spirits of nitre, potassium citrate, 
and cream of tartar water may advantageously be given to increase the 
flow of urine. 

The cause of the irritation should be diligently sought for, and when 
found should be appropriately treated. 

PASSIVE CONGESTION. 

In addition to the acute irritation of the kidney which has just been 
described, chronic passive congestion may occur, dependent upon dimin- 
ished arterial or increased venous pressure. This condition occurs in 
chronic cardiac disease with disturbance of compensation, in chronic pul- 
monary disease, and when there is mechanical obstruction to the venous 
circulation, as from the presence of abdominal tumors or ascitic fluid. 

Pathology. — The kidney is enlarged, firm, and of a deep-red color. 
The substance is tough from increase of interstitial tissue. The vessels 
are congested and their walls become thickened in long-continued cases. 
The epithelium of the tubules shows granular or fatty degeneration. 

Symptoms. — The symptoms which occur in the course of passive con- 
gestion are only slightly referable to the kidney, and depend for the most 
part upon the disease which causes the condition. 

Urine. — The urine in this condition is high-colored, strongly acid, and 
often considerably diminished in amount. It has a high specific gravity, 



DISEASES OF THE KIDNEYS. 353 

and often a heavy sediment of amorphous urates. The total solids are 
diminished absolutely, but owing to the concentration of the urine are 
relatively increased. There is a slight trace of albumin, usually under 
one-tenth of one per cent. Microscopic examination shows a few hyaline 
casts with renal cells adherent and an occasional blood-corpuscle. There 
are, however, very few of these elements in the sediment. If the urine 
is passed in larger quantities, it is not so highly colored and contains a 
smaller amount of albumin. 

Diagnosis. — The diagnosis of passive congestion from acute irritation 
usually cannot be made from the urine alone, owing to the association 
of the two conditions. The amount of blood elements in the urine is 
the principal test. The main reliance must be placed upon the clinical 
history and physical examination. 

Prognosis. — The prognosis in cases of passive congestion of the 
kidney depends upon the cause of the condition. 

Treatment. — The treatment is to be directed to the cause or causes of 
the congestion. 

ACUTE DIFFUSE NEPHRITIS. 

This condition is also described under the name Acute Bright' 's Disease, 
and also Acute Nephritis. 

Etiology. — The most common cause of acute diffuse nephritis in chil- 
dren is scarlet fever. Other diseases in the course of which it may arise 
are diphtheria, measles, varicella, erysipelas, typhoid fever, malaria, small- 
pox, meningitis, septicaemia, pertussis, and pneumonia. With the excep- 
tion of its occurrence in scarlet fever, diphtheria, measles, and pneumonia, 
the disease is not frequent. Cases have been reported in which it has arisen 
in the course of extensive affections of the skin, such as eczema. Cases of 
primary nephritis have been reported in which no cause could be found. 
Although it is difficult to estimate with certainty the importance of cold 
as a causative factor in the etiology of acute nephritis, and although it 
has been denied that cold can produce this condition, yet numerous cases 
have followed exposure to wet and cold. 

In most of the diseases due to infectious fevers the lesions in the 
kidney are dependent chiefly upon the action of the toxins. Some- 
times direct bacterial infection is a cause, and the course of the disease is 
especially severe in such cases. Any of the causes of active hyperaemia, 
described on page 851, may be a cause of an acute diffuse nephritis. 

Pathology. — According to Councilman, acute diffuse nephritis includes 
a number of different pathological conditions, described as (a) acute de- 
generative nephritis; (b) acute glomerular nephritis ; (c) acute hemorrhagic 
nephritis; and (d) acute interstitial nephritis. These forms have been 
described in some detail under scarlet fever, on page 549. 

From a clinical point of view, these various forms cannot always be 
differentiated by the character of the urine even when studied in connec- 
tion with the history and symptoms. It is probable that the urine in the 



854 PEDIATRICS. 

acute degenerative form of nephritis corresponds to that described under 
the heading of acute irritation of the kidney, and undoubtedly in many 
cases the pathological lesions are the same. 

Symptoms. — The symptoms of acute nephritis are such as have been 
already described under scarlet fever on page 572. In general, the symp- 
toms arising in cases due to other causes than scarlet fever are the same, 
but less severe than those described in connection with that disease. 
Briefly they may be stated to be, sudden onset with mild fever ; rapid 
development of anaemia ; swelling of the eyelids, face, ankles, and often 
general anasarca ; headache, thirst, nausea, and vomiting ; frequent mic- 
turition, but diminished quantity ; and in case of the advent of uraemia, 
stupor and convulsions. 

Urine. — The characteristics of the urine are generally described ac- 
cording to three recognizable stages. 

First or Acute Stage. — The quantity is very much diminished, at times 
almost suppressed. The color is dark, smoky, or blood-red. The re- 
action is acid, rarely alkaline from the presence of blood. The specific 
gravity is low or high ; it may be high from the presence of albumin. 
The normal solids are diminished both absolutely and relatively, especially 
the chlorine and urea. The albumin varies from one-fourth to one-half 
of one per cent. The sediment is abundant and is of a dark-brown color. 
There are large numbers of normal and decolorized blood-corpuscles and 
brown granular renal cells. Brown granular, epithelial, blood, fibrinous, 
and even hyaline and finely granular casts are seen in abundance. There 
may also be evidence of an acute pyelitis, as shown by clumps of caudate 
cells, round cells, and leucocytes. This stage lasts from five to ten days. 

Second or Fatty Stage. — In this stage the quantity of urine and solids 
excreted begins to increase, the albumin to diminish, and the sediment to 
become more dilute, with the same characteristics, but with the addition 
of fatty renal cells, fatty casts, and compound granule-cells. This stage 
lasts about as long as the first stage. 

Third Stage, or Stage of Convalescenec. — In this stage there is a 
marked increase in the quantity of urine, which gradually loses its 
dark and smoky color and becomes pale, faintly acid, of low specific- 
gravity, and with only a trace of albumin. The solids are nearly normal 
in absolute amount, but relatively are diminished, owing to the increased 
amount of urine. The sediment becomes slight in quantity, colorless, and 
shows a great diminution in the number of renal elements seen in the 
fatty stage. This stage may last from several months to several years, 
and be followed by complete recovery, especially in children. 

Exacerbations may occur at any time in the course of the second and 
third stages, and be followed by the return of the characteristics of the 
first stage. There is a sudden drop in the quantity of urine, with the re- 
appearance or increase of the blood elements, especially of fresh red blood- 
corpuscles, the amount depending upon the intensity of the exacerbations. 



DISEASES OF THE KIDNEYS. 855 

Complications. — Pneumonia, pleurisy, endocarditis, and pericarditis 
should all be carefully watched for, as they may occur any time in the course 
of an acute nephritis. Uraemia, however, is the condition especially to be 
guarded against. With a fall in the amount of urine and diminution in 
the amount of solids, as judged by a daily examination of the urea, 
special measures should be taken to increase the elimination of the toxic 
substances by diuresis, diaphoresis, or free catharsis. 

Differential Diagnosis. — The distinction between a severe acute de- 
generative nephritis and acute glomerular nephritis is to be made by the 
oedema, if present, and by the persistence of albumin, blood, and casts in 
considerable amounts in the latter condition. In the convalescent stage 
of an acute nephritis in which there is a large amount of urine and a 

Fig. 182. 




Acute diffuse nephritis, following scarlet fever. 

small percentage of albumin, the characteristics of the urine resemble 
those which occur in a chronic interstitial nephritis, but the history of an 
acute attack, the normal solids and presence of blood, and the rarity of 
chronic nephritis in children enable us to make the diagnosis. 

Cardiac disease with dropsy is to be distinguished either from acute 
diffuse nephritis or subacute glomerular nephritis by the evidences of 
valvular lesions and the character of the urine in cardiac disease, which 
is that of a passive hyperaemia or congestion. 

Fig. 182 illustrates the character of the dropsy which may occur in 
the course of an acute nephritis. The case is described on page 577. 

Treatment. — The treatment of acute nephritis consists primarily in 
the administration of a strict milk diet, rest in bed. and the free use of 
diuretics. The details of the treatment and of the complications which 
may arise, such as uraemia, have been sufficiently described in connection 
with nephritis following scarlet fever on page 573. 



856 PEDIATRICS. 

SUBACUTE GLOMERULAR NEPHRITIS. 

This condition is known also as " chronic parenchymatous nephritis." 

Etiology. — Chronic parenchymatous nephritis is not a common disease 
in childhood, and its etiology is still very obscure. Some cases have 
followed an attack of acute nephritis, and in these there has generally 
been an interval during which the urine has contained simply a trace of 
albumin and a few casts, the symptoms of a chronic affection of the 
kidney appearing later. Cases have also occurred in connection with 
long-continued suppurative processes in the bones, joints, or elsewhere, 
arising in the course of tuberculosis or syphilis. In these cases amyloid 
infiltration is also apt to occur. In the majority of instances no cause 
whatever can be discovered. 

Pathology. — The kidney is enlarged, pale, slightly mottled, and of in- 
creased consistency. The cortex is increased in width and is pale. The 
markings are indistinct. The essential lesions consist of swelling and in- 
crease in the nuclear elements of the glomeruli, with hyaline degenera- 
tion of the blood-vessels. There is proliferation and desquamation of 
the capsular epithelium and new formation of connective tissue. Diffuse 
degeneration and desquamation of the tubular epithelium and oedema of 
the intertubular tissue occur. (Councilman.) 

Symptoms. — The onset of subacute glomerular nephritis, or chronic 
parenchymatous nephritis, is sometimes insidious. Indigestion, loss of 
appetite, and vomiting are early symptoms. The face becomes pallid and 
"pasty," and oedema of the face, eyes, and ankles develops. Palpita- 
tion, headache, and dyspnoea, with hypertrophy of the heart and pulse of 
increased tension, are present and are often early symptoms. Epistaxis 
may occur. Nervous symptoms of a ursemic type are often pronounced, 
and in the more advanced stages of the disease may end in convulsions 
and coma. Changes in the retina are often found, and there is always a 
special tendency towards the development of intercurrent diseases, such 
as pneumonia and pleurisy, which often lead to a fatal conclusion. As 
the disease advances the oedema becomes more general, and a condition 
of anasarca develops. The anaemia becomes more profound and the 
cardiac symptoms more marked. 

Urine. — Micturition is frequent, but the quantity of urine which is 
passed is small. The disease is characterized by periods of activity and 
quiescence. In the active stages the oedema is increased, the quantity 
of urine is very small, and ursemic symptoms threaten. The urine is 
high-colored, strongly acid, with high specific gravity, and the solids are 
absolutely much diminished, although relatively they may be increased. 
The albumin is always very large, averaging from one-half to one per 
cent., although it is sometimes much higher. The sediment consists of 
many hyaline, granular, and fatty casts, some of which contain fatty renal 
cells and compound granule-cells adherent. These fatty degenerated 
cells are also found free. In advanced stages waxy casts will be met 



DISEASES OF THE KIDNEYS. 857 

with and are usually of bad prognosis. Signs of acute irritation of the 
kidney are often present and are indicated by the presence of blood 
elements. 

During the quiescent stage the dropsy becomes absorbed, and the 
oedema may entirely disappear. This change is associated with a marked 
increase in the quantity of urine, which may become normal or even 
in excess of the normal limit. As a result, the urine becomes pale, of a 
lower specific gravity, and with solids which are both relatively and abso- 
lutely diminished. The albumin remains high, ranging from one-fourth 
to one-half per cent. The sediment is the same as in the active stage, 
but the renal elements are less numerous. 

Diagnosis. — It is important not to diagnosticate this form of paren- 
chymatous nephritis when complicated with an active hyperemia with 
the second stage of an acute nephritis, for the prognosis is very different 
in the two conditions. The diagnosis can only be made by attention to 
the history of the case and to the changes which take place in the urine. 
If the case is one of a subacute glomerular nephritis complicated with 
hyperaemia, the blood elements of the acute process will subside in the 
course of a few weeks. 

Prognosis. — The prognosis is very grave. A few very rare cases of 
recovery have been reported. Most cases, however, die from uraemic in- 
toxication or from some intercurrent disease, such as pneumonia. There 
may be a remission in the symptoms for a time. The duration of the 
disease is from one to five years. 

Treatment. — The treatment of chronic parenchymatous nephritis is 
essentially the same as in acute glomerular nephritis. The diet should be 
restricted as far as possible to milk. Good hygienic surroundings and as 
much rest as possible are indicated. 

The use of diuretics and the treatment of general oedema and threat- 
ened uraemia have been described in detail in the chapter on scarlet fever 
(page 573). The anaemia is to be treated with iron, especially the tincture 
of the chloride, but the indications for iron should be determined by the 
blood examination and not from the pallor. Exposure to cold must be 
avoided, and residence in a warm, even climate during the winter months 
is very desirable. The skin must be kept active by bathing and friction, 
and moderate, regular exercise taken when the child is strong enough. 
Cardiac dilatation is to be combated with digitalis and strychnine. 

CHRONIC INTERSTITIAL NEPHRITIS. 
Chronic interstitial nephritis (chronic Bright' 's disease) is very uncom- 
mon in childhood. It is hardly practicable to attempt to make the dis- 
tinction between the various forms of chronic nephritis as can often be 
done in the case of adults. I therefore shall not describe chronic intersti- 
tial nephritis, chronic diffuse nephritis of the interstitial type, and chronic 
diffuse nephritis of the parenchymatous type as separate diseases. 



858 PEDIATRICS. 

Etiology. — The etiology of chronic interstitial nephritis is obscure. 
Hereditary tendencies and congenital syphilis play a part in the produc- 
tion of the disease in young children, but the common predisposing or 
associated conditions which are found in adults, such as gout, lead poi- 
soning, chronic alcoholism, and arterio-sclerosis are very rare in childhood. 
In some cases a subacute glomerular or chronic parenchymatous nephritis 
is followed by a chronic interstitial nephritis. 

Pathology* — The pathological conditions do not differ from the lesions 
as seen in the adult. The kidneys are very small and contracted with 
thick adherent capsules. The color is reddish, and on section the cortex 
is seen to be thin, the pyramids wasted, and the arteries thickened. The 
glomeruli are injected, and the pyramids show passive congestion. On 
microscopic examination the connective tissue between the tubules is 
much increased. The epithelium is degenerated. A general condition of 
arterio-sclerosis prevails. 

Symptoms and Diagnosis. — The diagnosis can scarcely be made from 
the symptoms. The disease is progressive and slow, with no character- 
istic symptoms. Cases have been reported in which there were headache, 
Aveakness, dyspnoea, palpitation, and disturbance of vision. Hypertrophy 
of the left ventricle, with a pulse of increased tension, occurs as a constant 
lesion. There is little tendency to oedema ; retinitis may be present. 
Sometimes severe nervous symptoms are prominent, such as tremor, 
increased reflexes, aphasia, and psychoses. Cerebral hemorrhages may 
occur as in adults. Baginsky refers to the lack of development of the 
children in these cases, and this condition was noticed in a case of this 
disease which occurred at the Boston Children's Hospital. 

This child, a girl, twelve years old, showed the development of a child of about 
seven years. The only symptom until she died of uraemic poisoning was persistent 
headache. The post-mortem examination showed marked interstitial nephritis, but it 
was not possible to determine whether it was primary or not, and no previous history 
could be obtained. 

Urine. — In chronic interstitial nephritis the amount of urine passed 
in the twenty-four hours is very greatly increased. It has a low specific 
gravity, a very slight sediment, and a trace of albumin. The microscopic 
examination shows a few hyaline and finely granular casts and occasional 
renal cells. Sometimes towards the end of the disease highly refractive 
homogeneous casts resembling wax appear in the urine. At this time the 
amount of urine may be somewhat diminished, but the specific gravity 
does not rise, as the excretion of urea is interfered with. 

Diagnosis. — The early stages are not recognizable. The cases demand 
careful observation for a long time and repeated examinations of the urine. 
The presence of cardio-vascular changes, such as cardiac enlargement 
and a pulse of high tension, are important. The condition must be dis- 
tinguished from physiological albuminuria and from passive hypersemia. 



DISEASES OF THE KIDNEYS. 359 

The distinction must be made principally on the clinical evidence of the 
symptoms and of the physical examination. 

Prognosis. — The prognosis is very unfavorable. The children usually 
die of cerebral hemorrhage or of some intercurrent disease. It is impossible 
to predict the duration of the disease from the symptoms or from the 
urinary examination. The presence of marked cardio-vascular changes, 
of oedema from failing compensation of the hypertrophied heart, and the 
continued excretion of very small amounts of solids, especially of urea, 
are unfavorable signs. 

Treatment.— The treatment of chronic interstitial nephritis is essentially 
the same as that of subacute glomerular nephritis. The diet, however, 
need not be so strictly limited. It should be light and nutritious and 
moderate in amount. Meat may be given in small quantities. Alcohol 
should be prohibited. Free use of the mineral waters is beneficial. In 
general, the indications are to maintain the functional activity of the heart, 
kidneys, skin, and bowels according to the methods which have been de- 
scribed. 

When the arterial tension is high, nitroglycerin may be tried. As 
evidences of failing compensation of the heart develop, appropriate sup- 
portive treatment with strychnine and digitalis should be given. Threat- 
ened uraemia is to be met by the same measures which have been de- 
scribed in connection with acute nephritis (page 573). 

AMYLOID INFILTRATION. 

Amyloid infiltration of the kidney may occur in the kidney in connec- 
tion with amyloid changes in other organs, especially in the liver, spleen, 
and intestines. It is always combined with other changes in the kidney, 
usually those of a chronic parenchymatous nephritis, and it is not to be 
considered as a separate disease of the kidney. 

Etiology. — It occurs at times in connection with chronic suppurative 
processes in the bones or elsewhere, and also in tuberculosis, syphilis, and 
chronic wasting diseases. It is not, however, especially common in early 
life. 

Pathology. — The amyloid change usually begins in the vessels of the 
glomerulus of the kidney, extends to other small vessels, and finally to 
the walls and epithelium of the tubules. The kidneys always show signs 
of diffuse nephritis. 

Symptoms. — The symptoms are those of chronic nephritis. The char- 
acter of the urine, the presence of a cause, and of amyloid changes in the 
liver and spleen, shown clinically by enlargement, are the signs by which 
the diagnosis is made. Hypertrophy of the heart is rare. The urine is 
usually passed in large quantity when the amyloid changes are advanced. 
The specific gravity is low, and albumin is present to the extent of from 
one-tenth of one per cent, to one per cent. When the amount of urine is 
not much increased, as may happen temporarily, the albumin occurs in large 



860 



PEDIATRICS. 



amount. Microscopic examination shows no characteristic sediment ; but 
when, as may often happen, the disease is combined with chronic nephritis, 
the sediment will show evidence of this latter disease. Waxy casts appear 
much earlier than in other forms of chronic nephritis. There are no fatty 
elements unless the disease is complicated. 

Prognosis. — On account of the usual causes of this condition the 
prognosis is unfavorable. 

Treatment. — The treatment is the same as that of chronic interstitial 
nephritis and of the primary disease upon which the amyloid changes are 
dependent. 

The case which follows illustrates a chronic parenchymatous nephritis 
with an acute exacerbation. 

The boy was eleven years old, and had had nephritis for one year. He had 
pertussis when he was three years old, scarlet fever when he was four years old, 
and measles and pneumonia when he was five years old. He is reported to have 
remained well from that time until nine months before he came under my observa- 

Fig. 183. 




Probable chronic parenchymatous nephritis with an acute exacerbation. Male, 11 years old. Relapse 

after being out of bed five days. 



tion, when, without any known cause, such as exposure to cold or sickness of any 
kind, his face and eyes began to be oedematous. This was followed by oedema of the 
legs and ankles, and was accompanied by dyspnoea. The urine was noticed to be 
nearly of the color of blood, and to be lessened in amount. He was kept in bed for 
six weeks, and is said not to have complained of any especial discomfort. During this 
attack his appetite remained fair. From the beginning of the attack he grew weak and 
pale. Six weeks before the present history the paleness and oedema about the eyes in- 
creased, and the urine became smoky again. This was followed by oedema of the 
ankles, feet, and legs, accompanied by dyspnoea. The bowels were regular, and there 
was no vomiting. Sleep was not disturbed. On entering the hospital his face looked 
pale and waxy. There was considerable oedema of the face, especially of the eyes. 
His tongue was slightly coated, and there was oedema of the ankles, feet, and legs. 



DISEASES OF THE KIDNEYS. 861 

Nothing abnormal was found in the heart or lungs, and there was no evidence of 
ascites. 

He was kept in bed and given a diet of milk. Under this treatment the cedema 
and anaemia disappeared rapidly, and in two weeks he was allowed to be dressed and 
about the ward. Five days later he again had cedema of the face, and was immediately 
put to bed. From 750 to 900 c.c. (25 to 30 ounces) of urine were passed in the 
twenty-four hours. An examination showed it to have a specific gravity of 1010, an 
acid reaction, to contain about 9 grammes (140 grains) of urea in the twenty-four- 
hour quantity, to have the chlorides diminished, and to contain 0.6 of one per cent, 
of albumin, but no sugar. The sediment showed numerous hyaline casts of medium 
diameter, some of large diameter from the straight tubules, many coarse and fine 
granular casts, numerous fibrinous casts, and many casts with renal cells adherent ; 
also epithelial casts and blood casts ; an excess of renal epithelium, most of it granular 
or fatty ; a large amount of abnormal blood, free fat, and fatty casts. His temperature 
varied from 36.6° to 37.2° C. (98° to 99° F.). 

After remaining in the hospital for two months, with temporary periods of im- 
provement, he was discharged in about the same condition as when he entered. 

The following represents another case of the same type. 

Fig. 184. 




Probable chronic parenchymatous nephritis with an acute 

week of the disease. 

This child had measles when she was two years old, scarlet fever when she was 
three years old, varicella when she was six years old, and pertussis when she was eight 
years old. She apparently recovered entirely from all these diseases, and was well 
until one week before entering the hospital, when, without any apparent cause, her 
face and feet began to swell. She complained of no pain, and had no other symptoms. 
There was marked and extensive oedema of the entire face, body, and limbs. There 
was also a pronounced pallor of the skin. Nothing abnormal was detected in the heart 
or lungs. There was no ascites, headache, nor discomfort. 

An examination of the urine showed the color to be pale, the reaction acid, the 
specific gravity 1012, and the sediment moderate ; it contained 0.25+ of one per cent, 
albumin, and no sugar ; the sediment contained considerable abnormal blood, some free 



862 PEDIATRICS. 

fat, and a number of hyaline and fine granular casts of medium and small diameter, 
many of them short and with fat-globules adherent. There were some fatty renal epi- 
thelium, leucocytes, casts with renal epithelium, and hyaline casts with a few renal cells 
adherent. There were also several fatty casts. The casts were not very numerous. 

She was treated by absolute rest in bed, bitartrate of potassium, digitalis, and a 
diet of milk. In about a week the oedema rapidly diminished and the urine increased 
in amount. An analysis of the urine at this time showed that the color was pale, that 
it had a specific gravity of 1010, a trace of albumin, and a slight sediment, consisting 
of a small amount of blood, renal epithelium, and a few casts with blood. The total 
amount of urine passed in the twenty-four hours was 2010 c.c. (67 ounces). 

An examination of the urine three weeks later showed the color to be pale, the re- 
action acid, the specific gravity 1014, the albumin 0.25+ of one per cent. It contained 
hyaline and fine granular casts of small diameter, many with fat-globules and renal cells 
adherent ; also free fat-globules, fatty and granular renal epithelium, some normal and 
abnormal blood, leucocytes, and squamous cells. The casts were not very numerous, 
and there was not much change from what was found in the urine three weeks pre- 
viously. At this time the urine again became scanty, and the oedema and pallor re- 
turned, but she did not complain of any discomfort. An examination of the urine 
eight weeks later showed it to be pale and cloudy, the reaction acid, the specific gravity 
1018, and that it contained considerable sediment, and albumin 0.25+ of one per cent. 
The sediment consisted chiefly of hyaline casts of medium and small diameter, many 
of them having renal cells and fat adherent. There were also a few finely granular 
casts, considerable abnormal blood, free fat, fatty renal cells, epithelium, leucocytes, 
and occasionally blood, epithelial, and fatty casts. 

ACUTE PYELITIS AND PYELONEPHRITIS. 

Etiology. — Pyelitis is an inflammation of the mucous membrane lining 
the pelvis of the kidney. After the pyelitis has lasted for a time, the sub- 
stance of the kidney may be involved and pyelonephritis results. The 
most common cause is the excretion of uric acid by the kidney, or pelvic 
calculi. It may less commonly be due to an extension upward of gon- 
orrhoea or cystitis from the ureter and bladder, or to tuberculosis of the 
kidney, or to malignant growths. There is also an infectious form which 
may appear in the acute infectious fevers, such as scarlet fever, typhoid, 
pneumonia, or malaria. Pyelitis due to a local cause is usually unilateral. 
The form which appears as a complication in fevers is usually bilateral. 
Some cases are apparently of primary infection. These are usually due 
to the bacillus coli communis. 

Pathology. — The acute cases show an acute catarrhal inflammation of 
the mucous membrane of the pelvis of the kidney. In chronic cases 
there is thickening of the membrane and occasionally a considerable 
accumulation of pus. In pyelonephritis the suppurative process extends 
into the kidney itself. 

Symptoms. — In an acute attack of the disease, such as is caused by 
uric acid or a calculus, there are often local pain, chills, and fever. Typi- 
cal attacks of renal colic, with vomiting, pain, and intermittent fever, may 
occur. Hematuria may be an early symptom. Micturition is frequent. 
If the condition be due to tuberculosis, malignant growths, or abscess 
of the kidney, there will be more or less cachexia and emaciation, and 



DISEASES OF THE KIDNEYS. 863 

there may be local pain and tenderness. Pyuria is often the only symp- 
tom in the cases complicating acute infectious diseases. Leucocytosis is 
generally present. 

Urine. — The diagnosis is made from the examination of the urine, the 
characteristics of which vary according to the extent to which the inflam- 
mation involves the parenchyma of the kidney. The quantity of urine 
excreted is small. The color is high, smoky, or blood-red, according to 
the amount of blood present. The specific gravity is generally high and 
the total solids absolutely diminished, but relatively increased. The quan- 
tity of albumin varies from a trace to one-fourth or to one-half of one per 
cent., or even higher, depending upon the severity of the involvement of 
the kidney itself. The microscopic examination shows sometimes the 
whole field to be filled with pus-corpuscles, at other times the pus is 
in clumps ; there are also present small round cells with single nuclei, 
from the pelvis or from the kidney, and more or less blood. The diag- 
nostic cell of pyelitis is the " caudate cell," which is a small cell about the 
size of a renal cell, having a single nucleus and a tail. These cells come 
from the superficial layers of the pelvis of the kidney, and may disappear 
from the sediment as the inflammatory process becomes subacute or 
chronic. If the kidney is affected there are casts of various kinds, hya- 
line, granular, epithelial, and blood. The casts may be hard to find if 
the field is filled with pus. The presence of tubercle bacilli in the sedi- 
ment, shown by appropriate methods of staining, establishes the diagnosis 
of tuberculosis. The tuberculin test may be used with advantage. When 
calculi are present, they usually cause local pain and tenderness and hsema- 
turia, and occasionally attacks of renal colic. In the freshly passed urine, 
uric acid is often present in the sediment in the form of irregular spicu- 
lated crystals. 

Diagnosis. — JN T ew growths are more apt to produce hemorrhages than 
pus. Pyelitis may usually be distinguished from cystitis by the history, 
the presence of caudate and round pelvic cells in large numbers, and the 
evidences of renal irritation. In cystitis, on the other hand, there is gen- 
erally vesical pain and tenesmus and large numbers of squamous and 
prostatic cells. It may be confirmed by the aid of the cystoscope. Cathe- 
terization of the ureters in older children, when possible, is of great aid 
in making a definite diagnosis. 

Prognosis. — The prognosis depends upon the cause. In malignant 
growths it is fatal. This is true to a greater or less degree when the tubercle 
bacillus is the cause of the disease, as in almost every case tuberculosis is 
present somewhere else in the body. When uric acid or a calculus is the 
cause, the prognosis is more favorable under appropriate treatment. 

Treatment. — Uric acid, if present, should be treated by neutralizing the 
acidity of the urine, by placing the child upon a mild and unirritating diet, 
such as milk, and by making it drink freely of water. Potassium citrate 
should be used to neutralize excessive acidity of the urine, or benzoic acid 



864 PEDIATRICS. 

if the urine is alkaline. Either may be given in doses of from 0.12 to 
0.30 gramme (2 to 5 grains) three or four times daily in from one to four 
ounces of water. Operative treatment is at times called for when a 
calculus is present. 

CHRONIC PYELITIS, 

Etiology. — Chronic pyelitis may occur from a number of causes, such 
as tuberculosis, as a result of acute pyelitis from any cause, from irrita- 
tion of crystals and calculi, especially when the outflow of the urine 
through the ureter is obstructed, and from a movable kidney. 

Symptoms. — The symptoms depend largely upon the cause and the 
manner in which the disease develops. There are often no symptoms at 
all, and again Ave may have those of acute obstruction of the urine. If 
there is retention of pus, fever, sweats, leucocytosis, and renal colic result, 
and the condition is spoken of as pyonephrosis. If the pus is discharged 
into the bladder, these symptoms rapidly subside, returning if the reten- 
tion recurs. 

Urine. — The urine is somewhat diminished in amount, pale, and very 
turbid, slightly acid in reaction, of low specific gravity, and with the 
normal solids diminished both absolutely and relatively. The albumin 
varies from a slight trace to 0.1 percent. The sediment is chiefly de- 
generated pus, with possibly a few blood-globules. Casts of large diameter 
from the straight tubules are generally present, but are hard to find. 
The presence of crystals may enable us to diagnosticate a pyelitis due to 
calculus, but concretions may exist without the crystals appearing in the 
urine. In all cases of chronic pyelitis the urine should be examined for 
tubercle bacilli. 

Prognosis. — The prognosis depends upon the cause. If the cause is 
removable and the involvement of the kidney is not severe, recovery may 
be expected. 

Treatment. — The medical treatment is essentially the same as in acute 
pyelitis, but the case should be referred to the surgeon if there is a 
reasonable chance of removing the cause by operation. 

PERINEPHRITIS. 

Perinephritis is an inflammation in the connective tissue about the 
kidney. It may end in resolution or suppuration. It has been con- 
founded not infrequently with hip disease or vertebral caries. The most 
important paper on perinephritis in children was published in 1880 by 
Gibney, who reported twenty-eight cases. 

Etiology and Pathology. — Perinephritis in children may be secondary 
to suppuration in the kidney, such as results from calculi or tuberculosis, 
or to disease of the suprarenal capsules or to trauma. It is more fre- 
quently primary. The cellular tissue about the kidney becomes inflamed, 
and in the majority of cases suppuration occurs. The pus may discharge 
outward in the ileo-costal space, or into the pleura or bowel. 



DISEASES OF THE KIDNEYS. 865 

Symptoms. — The onset may be acute or chronic. In the acute cases 
there is high fever, often with a chill. There is usually gastric disturbance, 
and the constitutional symptoms may be very severe. The bowels are 
constipated at times. There is usually local pain referred either to the 
hip or small of the back. The spine is painful and rigid, and the leg on 
the same side is drawn up as the movement of extension is productive 
of pain. General movements of the body are instinctively avoided by 
the patient. There is tenderness and resistance in the lumbar region, 
and later a tumor appears, in which deep fluctuation may sometimes be 
obtained. The size of the abscess may be very large. The cases which 
discharge into the pleura are usually diagnosticated as empyema. The 
character of the urine is rarely affected. The condition runs its course 
in from a few weeks to six months. 

Diagnosis. — Hip disease is likely to be confused with perinephritis, but 
the diagnosis is easy after careful examination. In hip disease the pro- 
cess is much more chronic, and the deformity is produced insidiously. 
Moreover, the pain is lower down, and there is tenderness over the joints. 
There is limitation of all the movements of the hip instead of extension 
alone. 

Perinephritis may give local signs similar to psoas abscess from spinal 
caries, but the characteristic changes and deformity of the lumbar verte- 
brae are absent. 

Perinephritis may be confused with typhoid fever when the consti- 
tutional disturbance is severe and prolonged and the local signs develop 
slowly. 

Prognosis. — The primary cases almost always end in complete re- 
covery. Peritonitis from rupture of the abscess is the most serious 
complication. 

Treatment. — The treatment is surgical. Rest in bed and hot local 
applications are first indicated, and later incision with free drainage of the 
abscess. 

HYDRONEPHROSIS. 

Hydronephrosis is a condition in which the pelvis and calyces of the 
kidney are dilated with fluid as a result of an obstruction to the outflow 
of urine. 

Etiology. — Hydronephrosis may be congenital, in which case it may 
be due to constriction of the ureter. Both kidneys may be affected, but 
usually only one is involved. When acquired it generally affects but one 
kidney, and may be caused by obstruction of urine either from above, 
such as may occur from an impacted calculus in the hilus of the kidney 
or in the urethra, or from below by the pressure from a tumor or from en- 
larged mesenteric glands. The effects are mechanical, and are due to the 
pressure on the kidney of the retained fluid, which leads to the gradual 
absorption of the parenchyma of the kidney. These tumors sometimes 



866 PEDIATRICS. 

acquire a large size. They are frequently associated with other deformity 
or degeneration of the kidney. 

Symptoms. — The main symptom of hydronephrosis is the presence 
of an abdominal tumor connected with the kidney. When the tumor has 
grown sufficiently large, fluctuation can usually be detected, and aspira- 
tion gives a fluid which ordinarily contains urea. Subjective symptoms are 
usually absent and urinary signs are rare. If only one kidney is affected, 
the other performs the function of both, and the general condition of the 
child may remain good. When both kidneys are affected, life is usually too 
short for the development of a tumor, and the condition is not recognized. 

Prognosis. — Bilateral cases are usually fatal within a year. If only 
one kidney is involved operation gives the only hope of relief. 

Treatment. — The treatment is surgical. Total excision of the kidney 
has given better results than incision and drainage. 

MALIGNANT GROWTHS AND ENLARGEMENT. 

Tumors of the kidney are more common in the child than in the 
adult. They are almost always primary and usually malignant. The 
simple adenomata are probably equally common in both, but the child 
is much more liable to carcinomata and sarcomata than is the adult. 
Sarcomata are the most common in the first five years of life, and usually 
occur in one kidney. 

Symptoms and Diagnosis. — The diagnosis depends upon the recognition 
of a tumor of the kidney, the hematuria, and the progressive emaciation 
and cachexia which arise. At times there is pain, but, as a rule, pain is 
absent. The urine sometimes gives evidence of a pyelo-nephritis ; haema- 
turia and albuminuria usually occur at intervals late in the disease, at a 
time when the tumor can be felt through the abdominal wall. The tumors 
are frequently of large size and rapid groAvth. They may cause symptoms 
by compression of the lungs, vena cava, or bowels. Ascites is sometimes 
present, and very rarely general peritonitis. Some of the characteristics 
of a tumor of the kidney are that it is located in the hypogastric and 
lumbar regions, is deep-seated, and is not so commonly to be felt in the 
umbilical region as are tumors of the retro-peritoneal glands. The tumor 
is irregularly rounded, and usually does not have a well-marked border, 
such as is found in enlargement of the spleen and liver. In these cases 
of sarcomata of the kidney the health at first is often not much affected, 
but there are progressive emaciation and enlargement of the abdomen,, 
commonly without pain. Malignant growths of the kidney may be con- 
fused with hydronephrosis. 

Prognosis. — The prognosis is very unfavorable, although temporary 
relief is sometimes obtained by means of surgical interference. 

Treatment. — The treatment is essentially operative. The total mor- 
tality of the operation, including cases of recurrence with death, is 
over seventy-five per cent. 



DISEASES OF THE BLADDER AND GENITALS. 867 

DISEASES OF THE BLADDER AND GENITALS. 

ACUTE CYSTITIS. 

Acute cystitis is not a common affection in infancy and childhood. 

Etiology. — It may be caused by a vesical calculus, by irritants, such 
as turpentine, and also occasionally by the extension of infection through 
the genital tract, but this is less common than in adults. It is not an 
infrequent complication of typhoid fever and many other diseases from 
direct infection by the bacteria which are eliminated by the urine. Gon- 
orrhoea and infections by the pyogenic organisms are direct causes of 
acute cystitis. It is more common in girls than in boys. 

Symptoms. — In children the chief symptom is frequent and painful 
micturition. This local symptom is usually accompanied by fever, which 
may be high, and by general symptoms of malaise, fretfulness, and crying 
from vesical pain and tenesmus. The urine is passed in small quantities, 
and, as a rule, is of a reddish color at first, and gradually becomes of a 
lighter color. The specific gravity is high. When freshly passed it is 
acid, but it quickly becomes alkaline ; there are a heavy sediment and a 
trace of albumin. Microscopic examination shows chiefly pus in large 
quantities, squamous epithelium, and some blood. To establish the diag- 
nosis in females it is sometimes necessary to examine a catheter speci- 
men. In infants the symptoms are so mild that the condition is often 
unsuspected. 

Prognosis. — The prognosis of acute cystitis is good after the removal 
of the cause. 

Treatment. — The especial cause of the attack must be looked for, and 
removed if possible. The child should be kept perfectly quiet in bed, 
and should be made to drink a great deal of water. The diet should be 
of milk. In the acute cystitis occurring in the course of typhoid fever, 
urotropin in doses of from 0.06 to 0.32 gramme (1 to 5 grains) four times 
a day acts almost as a specific in from four to seven days. In cystitis due 
to other causes it is not so serviceable, except as a preventive of fer- 
mentation of urine within the bladder. Sedatives should be used freely. 

CHRONIC CYSTITIS. 

Etiology. — Chronic cystitis may be caused in children, as in adults, by 
a vesical calculus, by foreign bodies in the bladder, by tumors, by papil- 
lomata, and by tuberculosis. The nuclei of the calculi are generally 
composed of uric acid, upon which phosphates are precipitated in alkaline 
urine, and this deposition is favored by the accompanying catarrhal in- 
flammation. 

Symptoms. — Micturition is frequent and at times painful. Later there 
may be a constant dribbling of urine, giving rise to an offensive ammo- 
niacal odor and causing irritation about the genitals. When there is a 
calculus in the bladder the stream is often suddenly interrupted during 



868 PEDIATRICS. 

micturition, and the pain is more severe. Prolapse of the rectum is not 
uncommon with stone. In addition to these local symptoms there are 
general symptoms of anaemia and loss of weight. The urine is ammo- 
niacal, offensive in odor, and turbid, has a heavy ropy sediment, and 
contains a trace of albumin. The sediment should be examined as soon 
as possible after the urine is passed, because the ammonia which is 
produced from the urea disintegrates the cells. The examination will 
show a large quantity of pus, some blood, bladder-epithelium, and crystals 
of triple phosphate and urate of ammonium. Tubercle bacilli may be 
found in the urine in tuberculosis of the bladder, but a prolonged and 
careful search is often necessary. 

Prognosis. — The prognosis of chronic cystitis depends upon the cause, 
upon the length of time during which the disease has persisted, and the 
presence or absence of a secondary infection of the kidney. 

Treatment. — The urine should be diluted by giving distilled water in 
large amount. It may be rendered less irritating by such drugs as salol 
and buchu, and less alkaline by benzoate of sodium. Urotropin given by 
the mouth has yielded excellent results by disinfecting the urine in the 
bladder and checking alkaline fermentation. Washing out the bladder 
with weak solutions of permanganate of potash, creolin, boracic acid, or 
lysol is of use in many cases, and local applications may be made in tuber- 
culosis of the organ. Operative treatment is indicated when a calculus is 
causing the disturbance. 

At times it is exceedingly difficult to determine by the general symptoms 
whether or not a calculus is present in the bladder. The following case 
may be cited as an illustration : 

A boy, seven years old, began to have pain of a spasmodic character in the region 
of the bladder during micturition. In connection with the pain there was a sudden 
stoppage of the flow of the urine and a bearing-down feeling in the rectum. These 
symptoms simulated those of a vesicle calculus so closely as to render a differential 
diagnosis very difficult. The boy was of a nervous temperament, and was rather 
anaemic, but otherwise was well and strong. Nothing abnormal was detected about 
the prepuce or the rectum. The pain was so annoying and caused so much trouble 
that it was deemed advisable to have the bladder examined for stone. An examination 
was made, but nothing abnormal was detected. After this a decided improvement took 
place, apparently connected with the passing of the sound, and the boy recovered 
entirely after remaining at home from school for a few weeks and having daily exercise 
in the open air. 

VULVO-VAGINTTTS. 

Vulvo-vaginitis is a very common affection in little girls. It arises 
from a variety of irritations, one of which is the oxyuris vermicularis. In 
a very large number of cases the gonococcus of Neisser has been found 
in the purulent secretion. The gonococcus was found in all of six cases 
lately treated at the Boston Children's Hospital. The disease may also 
arise in children who are very much debilitated, and is met with at times 



DISEASES OF THE BLADDER AND GENITALS. 869 

in scarlet fever and in measles. Again, it is not infrequent in anaemic 
girls, in whom it occurs without any apparent cause. 

Pathology. — The labia are reddened and are more or less swollen. 
There is a thick, purulent discharge of a greenish-yellow color, usually 
offensive. At times there is more or less excoriation of the inner surfaces 
of the labia. The inguinal glands may be slightly enlarged and tender. 
The urethra is often involved in the irritation, and is swollen and red. 

Symptoms. — There may be some fever in the early stages of vulvo- 
vaginitis. Smarting and burning are usually complained of, but at times 
the staining of the clothing first calls attention to the disease. The 
children commonly become pale if the disease persists for some time. 
Micturition is painful and frequent in some cases, and the disease is one 
of the many causes of dysuria. In many cases the children appear to be 
quite well, with the exception of the local condition. A positive diagnosis 
of gonorrhoea is only possible by means of a microscopic examination of 
the discharge after staining by Gram's method. 

Prognosis. — The prognosis is good, but the disease is apt to be pro- 
longed for several weeks or months. Complications may arise from the 
infection of the bladder, uterus, Fallopian tubes, inguinal glands, joints, 
or conjunctivae. Infection of the conjunctivae is common, infection of the 
uterus and other organs is much less so. 

Treatment. — Local applications to the vagina constitute the only satis- 
factory form of treatment. This is difficult in young children, but may 
be accomplished with a soft rubber catheter or with a soft rubber ear- 
syringe. Such solutions as boracic acid 1 to 40, corrosive sublimate 1 to 
5000, or creolin 1 to 500, may be used. In some severe cases local 
applications of nitrate of silver, 1 or 2 per cent., or of protargol, may be 
necessary. The labia should be kept separated by absorbent cotton, and 
the parts kept dry and covered with some mild dusting-powder. Abso- 
lute cleanliness must be observed, to prevent infection of the eyes and of 
other persons. The parts should be protected with compresses held in 
place by a bandage, which should be worn all the time, and the com- 
presses should be frequently changed and burned. The towels used for 
the patient should not be left lying about, and should be carefully dis- 
infected. Tonic treatment is sometimes indicated. The urine should 
be kept dilute, in order to avoid irritating the inflamed surfaces, and 
any complicating cystitis should be treated. During the active stage of 
the disease the child should be kept as quiet as possible, and on a diet 
of milk. 

When the vulvo-vaginitis is caused by the oxyuris vermicularis, 
especial care should be given to eradicating the parasite from the rectum, 
as described on page 830. After this has been done, the vagina is readily 
freed from the parasite by using an injection of warm sweet oil, which is 
to be allowed to remain for three or four minutes, the vagina then being 
syringed out with warm water. 



870 PEDIATRICS. 

ORCHITIS. 
Orchitis, or inflammation of the testis proper, occasionally results from 
direct injury, much more rarely from infection in gonorrhoea, syphilis, and 
tuberculosis. When present it is commonly accompanied by hydrocele. 
The orchitis which so commonly follows mumps in the adult is much less 
common in children. The treatment consists in support of the testicle by 
means of a suspensory or of a bandage. 

EPIDIDYMITIS. 

Acute epididymitis may be caused by trauma or by any irritation of 
the mucous membrane of the urethra. In this disease the whole scrotum 
is apt to be hot and tender, and the child is in great pain. The epi- 
didymis is much enlarged and exquisitely tender, and pushes the testis 
forward. The cord is often implicated, becoming enlarged and painful 
on pressure. 

The treatment should be energetic, as, owing to the swelling of the 
tissues about the testicle, there may be so much pressure that the gland 
will be seriously damaged, although the subsequent atrophy may not de- 
clare itself for a considerable time. The child should be kept upon his 
back in bed, the bowels freed with a cathartic, and a series of hot poultices 
kept upon the scrotum. In all inflammations of the testis or epididymis 
the scrotum should be placed in such a position that the lower end of the 
testicle points upward. 

TUMORS OF THE TESTICLE. 
In addition to tubercular disease of the testis, tumors may be found 
in infancy and in early childhood. These may be congenital or acquired. 
The congenital tumors are very rare, and are usually of the dermoid 
variety. The most common of the acquired tumors are carcinomata and 
sarcomata, which are very malignant. The rapid growth and the large 
size of this variety usually render the diagnosis easy. 

PHIMOSIS. 
In early life there appears to be a physiological adhesion of the pre- 
puce to the glans penis. As the child grows older these adhesions 
normally disappear. When the adhesion between the prepuce and the 
glans remains permanent and the prepuce is very tight, the condition gives 
rise to various symptoms. Thus the escape of the urine may be me- 
chanically hindered, and the urine collecting behind the glans may give 
rise to irritation. Smegma is also apt to collect around the corona. In 
this way an inflammatory condition of the prepuce (posthitis) or of the 
glans (balanitis) may arise. As a result of this there is swelling, and 
micturition is painful and difficult. In addition to these local symptoms 
many secondary disturbances arise from the local reflex irritation. Among 
these are nervous phenomena of greater or less degree, such as insomnia 
or convulsions. Phimosis may lead to enuresis and masturbation. 



DISEASES OF THE BLADDER AND GENITALS. 871 

In all cases of phimosis which give rise to symptoms of irritation local 
treatment is indicated, and may be by dilatation, incision, or circumcision ; 
the latter is the most radical and produces the best results for com- 
plete relief from the morbid condition. In all cases, even if the phimosis 
is very slight, mechanical interference should be persisted in until absolute 
cleanliness can be secured, for in this way only will entire relief from the 
local and reflex symptoms be obtained. 

ENURESIS. 

Enuresis (incontinence of urine) is a condition in which there is an 
involuntary discharge of the urine. It may be continuous or periodic. 
It may also be diurnal, nocturnal, or both. It is of very frequent occur- 
rence in infancy and early childhood. It is a symptom rather than a 
disease, and in most cases is a true neurosis. During the first year of life 
the infant has not learned to assume control of the mechanism of mictu- 
rition, but during the second year this control is usually attained at an 
earlier or a later period according to the individual. 

Etiology. — The causes of enuresis may be organic or functional, the 
latter in all probability being very commonly of a reflex nature. 

Organic Enuresis.-— The organic causes comprise such malforma- 
tions as small ureters, a small bladder, exstrophy of the bladder, and 
hypospadias. Enuresis may also be caused by central lesions of the brain 
and cord, such as tumor of the brain, idiocy, or injury to the cord. The 
prognosis and treatment of these organic cases of enuresis vary according 
to the conditions which cause them, and need not be considered here. 

Functional Enuresis. — In many cases the children are of a highly 
nervous temperament, but at times they do not show any nervous symp- 
toms. As has been stated by Rachford in an admirable paper on this 
subject, this condition may depend upon (1) irritable and unstable nerve- 
centres, (2) anaemia with malnutrition, and (3) reflex stimulation of certain 
nerve-centres in the lumbar cord. The longitudinal and circular mus- 
cular fibres of the bladder, which by their contraction empty the 
bladder, are innervated by sensory and motor nerves from the lumbar 
region of the cord, and the external sphincter in the prostatic portion 
of the urethra, which by its contraction prevents the escape of urine 
from the bladder, is also innervated by sensory and motor nerves from 
the lumbar cord. The researches of Von Zeissl show the manner in 
which reflex causes may act in starting or checking the flow of the urine. 
Thus, a reflex carried to the proper centre in the lumbar cord would, 
through the motor fibres of the erector nerve, contract the muscular coat 
of the bladder, and through the inhibitory fibres of the same nerve relax 
the sphincter vesica?. In this manner the urine which is being expelled 
by the contracting bladder is allowed to pass without hinderance through 
the relaxed sphincter vesica?. It is also to be remembered that the act 
of urination is in part under the control of the will. Admitting these 



872 PEDIATRICS. 

anatomical and psychical facts, it is easily understood how the causes 
which produce enuresis may act in two ways : either directly on the 
centres in the lumbar cord, making them more irritable or unstable, and 
in that way increasing their reflex excitability, or indirectly through ex- 
aggerated reflex causes that affect both acceleratory and inhibitory influ- 
ences sent to the bladder. These influences may be psychic, originating 
in the brain, or may be the result of external irritation originating in or 
near the bladder itself. 

There is also during childhood a lack of development of the centres 
of inhibitory reflex acts, and in this way the muscular fibres of the 
bladder, having no inhibitory restraint, are excited to action by even so 
slight a reflex cause as a small quantity of urine in the bladder. For this 
reason enuresis is a normal condition during infancy, and ceases when the 
child's inhibitory mechanism is more developed (Soltmann). The inhibi- 
tory influence of the will is in abeyance during deep slumber, and noc- 
turnal incontinence is therefore more frequent than diurnal. In any 
diseases which are accompanied by anaemia and malnutrition the reflex 
irritability of the lumbar nerve-centres is much increased and enuresis 
may result. Reflex enuresis may be caused by irritation in any portion 
of the genito-urinary tract, as by a vesical calculus, cystitis, vulvitis, 
phimosis, very acid urine, and over-filling of the bladder, as in diabetes, 
or by an irritation of some neighboring part, such as may arise from a 
fissure, polypus, or the oxyuris vermicularis in the rectum. 

Symptoms. — As a symptom, enuresis is simply the involuntary empty- 
ing of the bladder. 

Prognosis. — The prognosis of enuresis varies greatly, according to the 
cause and the individual. It is usually hopeless when it depends on 
disease of the brain or cord. In a large number of cases the enuresis 
lasts for only a short time, but in some cases it may continue throughout 
childhood ; almost invariably, however, it ceases between the twelfth and 
the fourteenth year. The cases in which enuresis does not disappear at 
puberty are nearly always in girls. 

Treatment. — The treatment of this functional form of enuresis is often 
prolonged and very unsatisfactory. According to my experience, in quite 
a number of cases the disease is intractable and is not affected by any 
treatment whatever, the individual finally recovering without treatment. 
Sometimes a habit of incontinence seems to have formed which continues 
after the removal of the original exciting cause. After a careful examination 
has shown that no malformation or central nervous lesion is present, the 
urine should be examined, to determine if it is abnormally acid. When 
this is found to be the cause of the irritation, a rapid cure can be effected 
in some cases by simply diluting the urine. In females, especially when 
there is irritation around the meatus urinarius, local applications are of 
great service, and in some cases dilatation of the urethra will produce a 
permanent cure. When phimosis is present, relief has sometimes been 



DISEASES OF THE BLADDER AND GENITALS. 873 

obtained by circumcision. The bowels should be regulated, little or no 
fluid should be given after five p.m., and it is well to have the child pass its 
water just before going to sleep, and to rouse it in the middle of the night 
in order that it may empty its bladder. The foot of the bed should be 
raised, in order that the urine shall not irritate the neck of the bladder. 
There is no especial drug which in my experience can be relied upon in 
curing enuresis. Attention to general hygiene is important. Plenty of 
sleep and a simple diet should be insisted upon. Punishment of the 
child is usually harmful, and should never be allowed. When the chil- 
dren are anaemic and debilitated, iron and mix vomica are indicated. 
When there is excessive irritability of the nerve-centres, belladonna and 
atropine are at times efficient in relieving this condition ; but in many 
cases they fail to produce beneficial results even when given in toxic 
doses. Faradism applied to the perineum or to the base of the sacrum 
and to the symphysis pubis is in some cases beneficial. If the bladder 
is contracted, daily dilatation up to the normal size with warm water may 
be very effectual. There is, however, no routine treatment for enuresis. 
Each case should be studied closely, and in many instances when the es- 
pecial cause of the condition has been found the enuresis can be relieved. 

MASTURBATION. 

Masturbation is one of the injurious habits of early life. It is most 
frequently practised during the later periods of childhood, especially be- 
tween the tenth and fifteenth years. It may. however, become a habit at 
any age, even in infants of one year. 

The inciting cause may be some local irritation, such as intestinal para- 
sites, concentrated and very acid urine, phimosis, balanitis, vaginitis, and 
a long prepuce. It may also be inculcated by the indiscreet handling of 
the genitals by nurse-maids. Not infrequently the habit is started from 
imitation of other children. 

There are no characteristic symptoms by which one can judge as to 
whether a child is a victim of this habit. The pallor, anaemia, dark rings 
under the eyes, headaches, and embarrassment which are sometimes men- 
tioned as distinctive signs, are common to so many other conditions that 
they are not sufficient evidence on which to make a diagnosis. Mastur- 
bation is stated by some writers to be a direct cause of insanity. 

The diagnosis of masturbation should only be made when the child 
has actually been observed to practise the habit on several occasions. 

The treatment in young infants consists in mechanical restraint, the 
hands and legs being so tied that the act becomes impossible. In older 
children strict surveillance should be kept. Punishment should be 
avoided. Moral persuasion, diversion of the mind, exercise, bathing with 
cold water, diet, and general hygiene are the main points in the treat- 
ment. In serious cases the bromides may be given. Hypnotism has 
proved very beneficial in many of these cases. 



DIVISION XV. 

THE BLOOD. THE LYMPH-NODES. THE DUCTLESS 

GLANDS. 



THE BLOOD IN INFANCY AND CHILDHOOD. 

The blood does not merely absorb the waste material from the tis- 
sues and carry fresh oxygenated material to replace it ; it plays a far 
greater part than this in the economy, and is intimately connected with 
many diseases, both through its corpuscular elements and its serum. 
An immense amount of labor has been expended on examinations of the 
blood, both chemical and microscopical, in adults, but our knowledge of 
the blood as it occurs in pathological conditions in infancy and in early 
life is still very incomplete and is wanting in exactness. 

Nomenclature. — The following nomenclature, with its accompanying 
plate, will explain the terms which are used in speaking of the various 
elements of the blood : 

Red Corpuscles Normal red corpuscles (Plate XII. ) 

(Erythrocytes. ) 

1. Hamiatoblasts Nucleated red corpuscles (Plate XII. ) 

(1) Normoblasts Size of erythrocytes, having a small deeply 

staining nucleus (Plate XII. ) 

(2) Megaloblasts .... Large nucleated red corpuscles, having a 

large, often fragmented, nucleus, staining 

faintly (Plate XII. ) 

(3) Microblasts Small nucleated red corpuscles. 

2. Microcytes Abnormally small erythrocytes (Plate XII. ) 

3. Macrocytes Abnormally large erythrocytes. 

or Megalocytes. 

4. Poikilocytes Abnormally shaped erythrocytes (Plate XII. ) 

White Corpuscles (Leucoc} r tes. ) 

1. Lymphocytes Pound mononuclear cells about the size of 

or small mononuclear. erythrocytes, with faintly staining proto- 
(Basophiles.) - plasm. The nucleus stains deeply, and 

fills nearly the whole cell (Plate XII. ) 

2. Large Mononuclear and 

Transitional Cells double the diameter of erythrocytes 

(Basophiles. ) with oval, round, or indented (transi- 
tional), faintly staining nucleus filling a 
relatively small part of the cell (Plate XII. ) 

874 



PLATE XII. 




Culex . 
( Resting Position. ) 




Anopheles 



Anopheles. 
( Resting Position.) 



W% 



V 



Plasmodium Malanae 

Oil I mmers. REICHERTXs 

Ocular N? 3, 



m 



; m 






r'V»: 



m 

*•!•;•/.? 



r-;f %mi 



%, 












« 












i- 







a' 



* 



! 



"V3 



> 



LEITZ Oil Immers.Jfa Ocular N?3. 



1. Normal Red Corpuscles. 

2. Haematoblastsor Nucleated Red 

a. Normoblasts.. Corpuscles: 

b. Me^aloblssrs. 

3. Microcytes. 

4. Poikilocytes. 

5. Lymphocytes or Small Mononuclear. 

6. Large Mononuclear; 
a. Transitional. 

7. PolynuclearNeutrophiles. 

8. Pol/nuclear Eosinophiles: 
a. Dwarf Eosinophil . 

9. Myelocytes: 

a. Neutrophilic. 

b. Eosinophilic. 



THE BLOOD IN INFANCY AND CHILDHOOD. 875 

3. Xeutrophiles Considered by most observers the oldest 

or polynuclear cells. variety of the leucocytes. The nucleus 
stains with basic stains ; the plasma stains 
faintly with neutral aniline stains, and the 
granules stain with a combination of both 
basic and acid stains, and hence are called 
neutrophiles. The nucleus is really poly- 
morphous, though sometimes (apparently) 
broken \. (Plate XII.) 

4. Eosinophils Polymorphonuclear cells characterized by 

(Oxyphiles. ) the presence of large, highly refractile 
granules which stain with all acid coloring 
matters (Plate XII. ) 

5. Myelocytes. . . . . Large, round, or ovoid cells with one (sel- 

or large mononuclear dom two) large faintly staining nuclei, 
neutrophiles. The plasma is filled with small granules 

that take (a) a neutral or (b) an acid stain (Plate XII.) 

(a) Neutrophilic (Plate XII. ) 

(b) Eosinophilic (Plate XII. ) 

Leucocytosis An increase in the whole number of leu- 
cocytes, or an increase in the proportion 

of any single variety. 

Basophilic Stained by basic stains. 

Acidophilic Stained by acid stains. 

or Eosinophilic. 

^Neutrophilic Stained by neutral stains. 

Polychromatophilic Taking more than one stain. 

Oligocythemia Eeduction in number of erythrocytes. 

Hemolysis Destruction of erythrocytes. 

Hemoglobix Coloring matter of the blood. 

ILemoglobixemia Presence of haemoglobin in the serum. 

Hemoglobinuria Presence of haemoglobin in the urine. 

Plate XII., facing page 874, shows all the principal normal and abnormal 
cells occurring in the blood in early life. The different types of anaemia 
are characterized by a combination of the different cells in varying pro- 
portions, and by becoming familiar with their microscopic appearance, and 
then in a given case by calculating the percentages of the different cells 
which are present we have a very valuable aid in diagnosis. 

THE BLOOD IN NORMAL CONDITIONS. 

There are certain general characteristics which must be recognized 
when we are dealing with human beings in the earlier stages of their 
development. 

These characteristics merely impress upon us that the blood, like the 
various organs and tissues, changes by a process of development from the 
fcetal to the developed condition of adult life. It is therefore necessary to 
take into consideration the age and stage of development of the individual 
whose blood we are examining before we can state that such a blood is 
normal or abnormal. For instance, just as it would be abnormal for the 
anterior fontanelle to be closed at the sixth month and unclosed at the 
twentieth month, so it would be abnormal for the blood of an infant in 
the early weeks of life to show the same ratio of leucocytes to erythro- 



876 PEDIATRICS. 

cytes as it would in adult life, or for the leucocytes to show the percentage 
of lymphocytes and polynuclear neutrophiles in the same proportion as 
at a later period. In fact, what I have already stated concerning the 
different stages of physical development holds true in the case of the 
blood, where what can be considered normal and physiological at one 
period becomes, if it lasts into another period, abnormal and significant 
of disease. In order to understand, therefore, the diseased conditions of 
the blood we must remember what is normal at each period. We will 
next consider the normal condition of the blood at birth and its various 
stages of development. 

Amount of Blood at Birth. — Welcker states that the total amount of 
blood at birth is one-nineteenth of the body- weight. His opinion is based 
on the examination of a poorly developed infant, in which the umbilical 
cord was ligatured immediately at birth. 

Schuecking places the amount at one-fifteenth of the body-weight, 
from an examination of five full-term infants, without expressing the 
blood from the placenta, and with immediate ligature of the cord. When 
the cord was tied later, and the so-called "reserve" blood was expressed 
from the placenta, the percentage rose to one-ninth. In adults the re- 
lation of the blood to the body-weight is stated to be one-thirteenth. All 
authors agree that there is a temporary gain in the amount of blood when 
the cord is tied late. 

Reaction. — The reaction of the blood at birth is always alkaline. 

Color. — The color is found to be darker in the capillaries during the 
first few days than at any other time. 

Specific Gravity. — At birth the specific gravity of the blood is about 
1065, and this does not vary for the first few weeks. Then for a varying 
number of months there is a constant diminution, decreasing in boys to as 
low as 1048, and in girls to 1050. It then gradually rises, till at the end 
of the first year it has reached the normal average of 1052 to 1055 
(Hock and Schlesinger). The specific gravity does not seem to be in- 
fluenced by the number of red or white corpuscles, food, rest, exercise, or 
other causes, but depends directly upon the amount of haemoglobin. As 
a whole, the specific gravity is, apart from physiological variations, very 
constant in the same individual, and remains for weeks and months the 
same. Hock and Schlesinger place the greatest twenty-four-hour varia- 
tion at 0.00025. The appearance of the child's skin is not an index to 
the specific gravity of the blood or to the amount of the haemoglobin. 
Children often appear anaemic without any especial alteration in either of 
these conditions. 

Haemoglobin. — The haemoglobin is found to be less firmly bound to 
the red corpuscle in the infant at term than it is in adults. It is, however, 
proportionately greater in amount at birth than in adult life. The haemo- 
globin, like the specific gravity, which is closely dependent upon it, 
reaches its maximum at birth. Starting at 100 or 104, it falls rapidly to 



THE BLOOD IN INFANCY AND CHILDHOOD. 877 

its minimum in the first three weeks of life (Hock, Schlesinger, Widowitz, 
Schmaltz, and Hammerschlag). The lowest percentage that has been 
found is about fifty-five per cent. From two weeks to six months it re- 
mains about the same and then rises slowly. The average figure for 
infants and children is sixty to eighty per cent. The percentage of haemo- 
globin varies greatly not only between different individuals, but also in 
the same individual, which may explain the great discrepancy in the 
figures given by various authorities. Haemoglobin is more abundant in 
boys than in girls. 

Red Corpuscles (erythrocytes). — All authors agree that there is a 
large number of red corpuscles at birth, and also that an increase occurs 
in the first twenty-four hours. As regards the actual number in the 
cubic millimetre of blood there is much diversity of opinion. Hayem 
has found a larger number at the moment of birth than in the mother's 
blood, and gives as an average 5,350,000 ; Shiff says 5,800,000. The 
increase after birth is only seeming, according to Shiff, and is clue to a loss 
of fluid and consequent concentration of the blood. From the -second 
day the red cells begin normally to diminish, and fall eventually, according 
to Lepine, Jerrard, and Schlemmer, to 5,000,000. In infancy the average 
number is from 4,000,000 to 5,500,000 ; in later childhood from 4,000,000 
to 4,500,000 (Hayem). There is much greater variation in size in the red 
corpuscles of the newly born than in those of older children or adults, 
and microcytes are more numerous ; the oscillations in the number of 
red cells within twenty-four hours are also much more marked than in 
adults. 

H/Emato blasts. — Hgematoblasts or nucleated red corpuscles are nor- 
mally present in the foetal blood and diminish in number towards the end 
of pregnancy. They also occur in the blood of premature infants, and 
are present in small numbers in the blood of normal infants for a few 
days after birth and then disappear. After six months they are rarely or 
never found normally. Pathologically their presence may be of con- 
siderable importance, and the younger the child the less intense need the 
anaemia be which will cause their appearance in the blood. 

Leucocytes. — The leucocytes, or white corpuscles, are more numerous 
at birth than in adults and in young children. In the first twenty-four 
hours the number varies from 18.000 to 30,000 (Schiff, Gundobin, 
Hayem). This is rapidly reduced at the end of ten days to from 14,000 
to 10,000. The daily variations in the early days of life are more marked 
than in adults, and the leucocytosis of digestion is relatively higher. The 
average number of leucocytes in an infant's blood after the first two or 
three weeks and up to six months is from 12,000 to 14,000, and from six. 
months to one year from 10,000 to 12,000. Denis places the number 
of white cells from the second to the sixth year at from 9000 to 10,000. 
Bouchut and Debrisay found the average number of counts in children 
from two to fifteen years of age to be 6700. 



878 PEDIATRICS. 

The following figures compiled by R. C. Cabot show the normal 
average number of blood-corpuscles at different ages in cases in which 
there was a loss of weight in the first forty-eight hours. 

TABLE 73. 
Normal Average Number of Blood-Corpuscles at Different Ages in Cases in which there was 
a Loss of Weight in the First Forty-eight Hours. 
Age. Erythrocytes. Leucocytes. 

At birth 5,900,000 21,000 

(26,000 to 36,000 
after first feeding. ) 

End of 1st day 7,000,000 to 8,800,000 24,000 

" 2d " generally increased. 30,000 

" 4th " 6,000,000 20,000 

" 7th " 5,000,000 15,000 

10th day 10,000 to 14,000 

12th to 18th day 12,000 

1st year 10,000 

6th year and upward 7, 500 

Five varieties of white corpuscles are found normally in human blood, 
and these are classified as follows by Ehrlich : 

1. Lymphocytes (Plate XII. , facing page 874).— These are about the 
size of a red corpuscle, and contain one large, round, deeply staining 
nucleus which entirely fills the cells. The protoplasm is not granular 
and stains faintly or not at all. 

2. Large Mononuclear (Plate XII.). — These cells are much larger than 
the lymphocytes. They have one large oval nucleus with a broad margin 
of non-granular, almost colorless protoplasm about it. 

3. Transitional (Plate XII.). — These cells are derived from the last 
form and are similar in size and color. The nucleus is indented on one 
side as the result of the beginning of nuclear division. 

These three varieties are sometimes called basophiles. (Hewes.) 

4. Polynuclear Neutrophils (Plate XII.).— These are round cells, 
smaller than the large mononuclear, having a peculiar polymorphous 
deeply staining nucleus. The nucleus is long, irregular or twisted, and 
when stained often appears segmented. The protoplasm contains fine 
granules which are stained by neutral stains. 

5. Polynuclear Eosinophiles (Plate XII.). — These cells are usually about 
the size of neutrophiles and have a deeply stained polymorphous nucleus. 
The protoplasm contains granules which are much coarser than those of 
the neutrophilic cells, and which stain readily with acid stains. 

These cells are sometimes called oxyphiles. (Hewes.) 

6. Myelocytes (Plate XII.). — These are round or ovoid cells with one, 
rarely two, large round or slightly bent nuclei which stain light blue. 
There are two varieties, neutrophilic and eosinophilic. The first has a 
protoplasm crowded with fine neutrophilic granules. The second con- 
tains coarse eosinophilic granules. Myelocytes rarely, if ever, appear in 
normal blood, but are much increased in some of the pathological states. 



THE BLOOD IN INFANCY AND CHILDHOOD. 879 

Percentages of Various Leucocytes in Normal Blood. — Concerning the 
percentages of the different leucocytes in normal blood, it is sufficient to 
say that the blood of infants differs from that of adults in that the blood 
of the latter contains from 62 to 70 per cent, of neutrophils, the re- 
maining 40 to 25 per cent, being made up of mononuclear cells, of which 
about 28 per cent, are lymphocytes. The following figures illustrate this : 

TABLE 74. 

Adults. Infants. 

Small mononuclear 20 to 30 per cent. 50 to 70 per cent. 

Large mononuclear 4 to 8 " 6 to 14 " 

Neutrophils .. : 62 to 70 " 28 to 50 " 

Eosinophils J to 4 " £ to 10 " 

Gundobin finds very little change from the above figures until the 
beginning of the third year, when the blood resembles more that of adults, 
the neutrophiles and mononuclear elements being present in about equal 
proportions. In children of eight or ten years he found very little 
difference from the blood of adults. His conclusions are that an infant's 
blood is (1) richer in white corpuscles ; (2) richer in young form elements, 
the absolute and relative counts of the lymphocytes being three times as 
large as in the blood of adults, while the " overripe" elements, or neu- 
trophiles, are half as many ; (3) in infants the white corpuscles remain 
relatively longer in the "unripe," and in adults in the "overripe" stage. 

Variations in temperature and physical exertion seem to have no 
effect upon the number of white corpuscles, but digestion leucocytosis 
is often quite pronounced. Most authors place the normal percentage of 
eosinophiles between 2 and 10 per cent. It is safe to say that they may 
be somewhat increased, even considerably, in infants' blood without 
having the same significance as in adults' blood. 

THE BLOOD IN ABNORMAL CONDITIONS. 

It is recognized that all the signs by which sickness is shown in the 
blood of adults are exaggerated in that of children. In my clinical work 
among infants I have noticed that their blood is much more sensitive to 
the action of adverse influences, such as poor air, improper hygienic 
surroundings, improper food, the inhalation of arsenic, and numerous 
other causes, and that anaemia is much more easily induced than in adults. 
This is especially noticeable in the impoverishment of the blood which 
follows gastro-enteric disease. Not only is an anaemic condition of the 
blood acquired by these influences, but also in congenital weaknesses 
which may be represented by infantile atrophy, or in some other inherited 
diseases, such as tuberculosis and syphilis, or in such acquired diseases as 
rhachitis, the development of the blood may be retarded. In this class 
of cases the blood of a child three or four years old may show no higher 
degree of development than that of a healthy infant in the second year. 
It is also found that when certain diseases occur in young children the 



880 PEDIATRICS. 

blood is apt to revert to a more infantile condition, and that the normal 
leucocytosis of infancy may represent disease at a later period. Again, 
the erythrocytes under certain morbid conditions may revert to an earlier 
type, such as nucleated corpuscles. One of the most important points to 
be remembered is that a physiological leucocytosis depending upon 
digestion is commonly met with in iufancy, and to a much greater degree 
than at a later period of life, so that what would be a normal leucocytosis 
at different times of the day, in reference to the food which has been 
taken, must always be borne in mind. It is therefore evident that when 
we are considering the blood of an infant or young child in any given 
disease we should take into consideration what the conditions of the 
blood usually show in the individual, — namely, as to whether a normal 
condition, according to the age, was present before the onset of the 
disease, or whether the especial individual had already an abnormal 
blood from backward development or from some inherited or congenital 
condition. Enlargement of the spleen in infants is not so significant as 
in adult life, for whenever anaemia is present there is apt to be an asso- 
ciated enlarged spleen. 

A classification of diseases of the blood is as difficult to make and as 
unsatisfactory as that of infectious and non-infectious diseases. It is 
probable that all the anaemic conditions of the blood will in the future 
be proved to be secondary, but when the causes of the pathological con- 
ditions found in the blood are difficult to find, or apparently are insuffi- 
cient to cause so severe a disease as is present, we speak of primary 
anaemia, while we speak of secondary anaemias as those which have some 
obvious cause, such as rhachitis, malaria, syphilis, hemorrhage, or any 
debilitating disease which causes a reduction in the normal constituents of 
the blood. 

Specific Gravity. — In various pathological conditions the specific 
gravity of the blood may be increased or diminished. Its changes usually 
run parallel Avith those in the amount of haemoglobin, on which, in fact, 
it is largely dependent. It is diminished in all forms of primary and 
secondary anaemias, being most diminished in leukaemia and pernicious 
anaemia (1028). It is usually diminished in nephritis (1040) as a result of 
the small amount of albuminous substance in the serum. It is sometimes 
increased in cardiac affections, and especially in tubercular meningitis. 

Hemoglobin. — In children the variation in the amount of haemoglobin 
present from day to day is more marked than in adults, boys usually 
having more haemoglobin than girls. It is diminished in secondary 
anaemia and in chlorosis, and lowest in leukaemia and pernicious anaemia 
(15 to 20 per cent.). 

Red Corpuscles (erythrocytes). — A diminution in the number of red 
corpuscles is found in a large number of acute and chronic diseases, 
especially in those accompanied by a marked anaemia. Instances of these 
diseases are rhachitis, syphilis, tuberculosis, malaria, and chronic ileo- 



THE BLOOD IN INFANCY AND CHILDHOOD. 881 

colitis. In leukaemia, and especially in pernicious anaemia, the number 
may fall to 500.000 per cubic centimetre. Certain drugs, such as arsenic, 
may in poisonous doses cause a marked diminution in the number of red 
cells. In recovery from acute anaemia the red cells regain their normal 
number much more rapidly than they do their haemoglobin. The red 
corpuscle, which normally has a size of from six- to nine- thousandths of 
a millimetre, may undergo changes in size or shape, and cells much 
smaller (microcytes) or larger (macrocytes) than the normal red corpuscles 
may appear, also cells having oval, pointed, or irregular forms (poikilo- 
cytes). I have already spoken of the fact that nucleated red corpuscles 
are found normally in the blood of young infants. They also readily ap- 
pear in quite large numbers in anaemia. There is, however, an essential 
difference in their significance in adults and in young children. In the 
former they only appear at a late period in severe anaemia, and therefore 
have a grave significance, while in children they readily appear in the 
blood in simple anaemias which go on to recovery. 

White Corpuscles {leucocytes). — The white corpuscles are affected in 
a temporary or permanent manner by many physical and pathological 
conditions in the body at large as well as in the blood-forming organs. 
The most common change from the normal is that of leucocytosis. Leu- 
cocytosis was originally described by Ehrlich as the presence in the blood 
of a greater number of white cells than normal for the individual, or a 
relatively increased number of any variety of white cells, with or without 
an increase in the total number of leucocytes. Cabot has restricted the 
term leucocytosis to an increase of leucocytes in which the polynuclear 
cells predominate, and uses the terms lymphocytosis and eosinophilia to 
describe a relative increase of the lymphocytes and eosinophiles. Physio- 
logically, we find a leucocytosis after the ingestion of any proteid food. 
It is at its height about two hours after a meal, when the total number 
of leucocytes may be as great as from 13,000 to 30,000, according to 
the age of the child. Pathologically, a leucocytosis follows a consider- 
able number of diseases, and seems in a general way to depend upon the 
amount of local reaction to which the disease gives rise. We find a 
pronounced leucocytosis in most fevers and in most septic processes. In 
these cases the increase is almost wholly composed of the polynuclear neu- 
trophiles, winch may make up from 90 to 98 per cent, of the entire leuco- 
cyte count. The leucocytosis does not depend on the degree of fever, 
does not always occur with it, and conversely inflammatory leucocytosis 
may appear before the fever. Pneumonia shows generally a leucocytosis. 
In pneumonia the large increase in the number of leucocytes seems to 
follow closely the course of the pathological process, and the •• blood 
crisis" is found to anticipate the ''temperature crisis" by some hours. 
Pericarditis and endocarditis, advanced pulmonary phthisis, pleuritis, 
erysipelas, acute rheumatism, purulent meningitis, pharyngitis, diphtheria, 
septicaemia, osteomyelitis, scarlet fever, variola, tonsillitis, bronchitis, 



882 PEDIATRICS. 

peritonitis, acute nephritis, gastro-enteric inflammation, rhachitis (espe- 
cially basophiles), some profound anaemias, whether primary or secondary, 
leukaemia, hemorrhage, malignant new growths, abscess of any kind, in- 
cluding appendicitis, and many skin diseases are among the affections that 
show leucocytosis. In leukaemia the leucocytes are increased more than 
in any other disease, they may reach 500,000 per cubic millimetre, and 
the proportion of the white to the red corpuscles may be 1 to 20 or even 
1 to 6. Certain drugs cause leucocytosis, such as pilocarpine, antipyrin, 
thyroid extract, and tuberculin. 

The diseases in which the leucocytes are approximately normal are 
malaria, tubercular meningitis, tubercular and serous peritonitis, influenza, 
measles, typhoid fever, pulmonary tuberculosis (unless there is a secondary 
infection by other bacteria), rubella, mumps, and most cases of epidemic 
influenza. Comparing these two lists it will be seen that there are in- 
stances in which the leucocyte count may be of great importance to the 
physician in making a differential diagnosis. By its aid we may in some 
cases differentiate scarlet fever from measles, a purulent from a tubercular 
meningitis, and a beginning pneumonia from a tubercular meningitis or 
typhoid fever. We may also differentiate typhoid fever from appendi- 
citis, and from osteomyelitis, from ileo-coiitis, and from septicaemia, also 
tubercular peritonitis from septic peritonitis. Lastly, we may by the 
leucocyte count alone be able to distinguish between sepsis and malaria 
in a patient whose only symptoms are malaise and returning chills. 

LEUKiEMIA. 

The disease called leukaemia sometimes occurs in infancy and child- 
hood. Klebs, von Jaksch, and Sanger describe congenital cases. On the 
whole, it is a rare disease in infancy, and when it occurs it is probably 
always a mixed form. A pure myelogenous form of leukaemia is very 
rare. The etiology of the disease is obscure. Cases have been reported 
which followed congenital syphilis and rhachitis. It is thought by some 
to be an infectious disease, but the evidence is insufficient. Von Limbeck 
thinks that it is a disease of the lymphatic system. Others say that any 
anaemia or Hodgkin's disease may progress to leukaemia under certain cir- 
cumstances, as may also anaemia infantum pseudo-leukaemica. A number 
of the cases are apparently primary. Males are more prone to the dis- 
ease than females. The essential feature is a persistent increase in the 
number of the white corpuscles of the blood, associated with changes in 
the spleen, lymph-glands, or bone-marrow. 

Pathology. — Leukaemia is a rare affection in infancy and childhood, 
and the recorded observations of these cases in early life are very in- 
complete. In the splenic myelogenous form the spleen is much enlarged. 
The condition of the organ is one of chronic hyperplasia, often with 
grayish-white lymphoid tumors scattered through it. The essential 
change in the bone-marrow is a great hyperplasia of the red marrow, 



THE BLOOD IN INFANCY AND CHILDHOOD. 883 

which contains large numbers of nucleated red corpuscles in all stages of 
development, also myelocytes and other cells. In the lymphatic form of 
the disease there is a general enlargement of the lymphatic glands and 
other lymphoid tissues as a result of simple hyperplasia. This is usually 
associated with a moderate enlargement of the spleen. The liver, as a 
rule, is considerably enlarged in both forms of leukaemia. 

Leukaemia is one of the few diseases which can be diagnosticated 
definitely from the blood examination alone. There is a more or less 
marked diminution in the number of the red corpuscles, the blood count 
ranging from 2,000,000 to 4,000,000, except in the early stages, with 
some irregularities in the size and shape of the corpuscles. The haemo- 
globin is usually much diminished. The important change is in the leu- 
cocytes, which are enormously increased in number, the proportion being 
frequently 1 to 15 of the red, and sometimes even 1 to 3. In the splenic 
myelogenous form the chief point of interest is the great increase in the 
number of myelocytes, which average about 35 per cent, of the white 
corpuscles, and may be even 60 per cent. The eosinophiles are some- 
times relatively increased. The percentage of polynuclear neutrophiles is 
usually diminished, and the lymphocytes show a great relative diminu- 
tion. Many nucleated red cells are present. In the lymphatic form the 
character of the blood is materially different, and the increase in the 
number of leucocytes is not usually so great. The increase is due solely 
to the lymphocytes, all the other forms being greatly diminished rela- 
tively. Eosinophiles and nucleated red cells are rare. Myelocytes are 
not present or are rare. This description of the blood applies to chil- 
dren as well as to adults, but there are practically no complete data as 
to the character of the blood of leukaemias in infancy. 

Symptoms. — The onset is insidious, and usually the first striking signs 
are progressive enlargement of the abdomen, enlarged glands, shortness 
of breath, and general weakness or hemorrhages from the mucous mem- 
branes. The progress of the disease is usually much more rapid in chil- 
dren than in adults. The symptoms are similar in the two types of the 
disease. The lymphatic form of the disease is more common than the 
splenic myelogenous in infants and children. The child becomes gradually 
pale and weak, and suffers from dyspepsia and repeated diarrhoea. The 
respirations are accelerated, and dyspnoea is shown on slight exertion. 
Fainting attacks may occur. Hemorrhage from the nose is common, and 
may occur from the stomach, intestine, or kidneys, or into the skin. The 
pulse is usually rapid and soft. There are rarely any cardiac symptoms. 
Headache and vertigo are marked at times. Vision may be much im- 
paired as the result of retinal hemorrhages or leukaemic plaques. Tender- 
ness over the shafts of the long bones has been occasionally observed. 
The urine presents no constant changes. It occasionally contains albumin 
and casts. A moderate degree of fever is usually present in the late 
stages, also oedema of the feet and general anasarca. 



884 PEDIATRICS. 

The following table shows the average percentages of the different ele- 
ments of the blood in the splenic myelogenous and lymphatic leukaemias : 

TABLE 75. 

Average Percentages of the Different Elements of the Blood in the Splenic Myelogenous and 

Lymphatic Leukaemias. 

Splenic Myelogenous Lymphatic Leu- 

Leukaemia, ksemia. 

Haemoglobin 25 to 50 per cent. 25 to 40 per cent. 

Bed corpuscles 2,000,000 to 3,000,000 2,000,000 to 3,000,000 

White corpuscles 100,000 to 400,000 50,000 to 100,000 

Lymphocytes 10 per cent. 96 per cent. 

Polynuclear leucocytes 50 " 3 " 

Eosinophils 5 " rare. 

Myelocytes 35 " usually absent. 

Nucleated reds very numerous. rare. 

Diagnosis. — A distinction is chiefly to be made between leukaemia 
and Hodgkin's disease, or secondary anaemia Avith leucocytosis, which 
in infancy is often accompanied by an enlarged spleen. The difference 
between leukaemia and pseudo-leukaemia, if such can be said to exist, is 
explained on page 888. 

The differential diagnosis of leukaemia is impossible by means of the 
clinical history, and can be made only by examination of the blood. The 
increase in the number of leucocytes is far greater, as a rule, in leukaemia 
than in other conditions, but the characteristic feature in the splenic 
myelogenous form is the presence of abnormal cells, namely, the myelo- 
cytes, and in the lymphatic form a great absolute and relative increase of 
the mononuclear cells. In Hodgkin's disease and in the secondary anae- 
mias with leucocytosis there is a simple increase of the normal forms of 
leucocytes. In some cases of Hodgkin's disease also the blood may be 
normal. Chronic adenitis, which might be confounded with lymphatic 
leukaemia, shows usually normal blood, and is thus readily differentiated. 
In distinguishing between the two forms of leukaemia we rely much more 
on the quality of the blood than on the other clinical characteristics. 

Prognosis. — The course is chronic and usually progressive, although 
recovery occasionally occurs. The great majority of cases prove fatal 
within a few months, although occasionally cases have been reported of 
three to five years 1 duration. Epstein and others have described an acute 
form with a rapid course of a few days or weeks. High fever, frequent 
hemorrhages, and marked oedema are unfavorable symptoms. The lym- 
phatic cases run a shorter course and are more uniformly fatal than those 
of the splenic myelogenous type. 

Treatment. — As in all cases of anaemia, fresh air and careful feeding 
are important indications. We have no specific for the disease, and the 
results of treatment by drugs of any kind are discouraging, although an 
occasional rare recovery has been reported. Arsenic given in large doses 
has proved the most efficient remedy. Iron is also of some value. Or- 



THE BLOOD IN INFANCY AND CHILDHOOD. 885 

ganotherapy has been used lately with some success. Bigger, de Feo- 
dosia, and Whait reported cases of rapid improvement after giving bone- 
marrow by the mouth. A glycerin extract of the spleen has been tried 
with little success. The results of splenectomy thus far indicate that it 
is not a desirable measure. 

The following case of acute leukaemia occurred in the practice of 
Dr. Morse : 

The child, a girl, was three years old and was healthy at birth. Her mother had 
died of pneumonia when she was two years old. Her father was well. There was no 
tubercular or syphilitic history. She was nursed for a year and then fed from the 
table. She was always subject to diarrhoea, but otherwise had been well. No history 
could be obtained except that six days previous to being seen blood-spots had appeared 
on the skin and the mouth had become sore. She had also vomited blood and had 
passed some blood from the bowels. 

She looked seriously sick and was very pale, but was fairly developed and was not 
especially thin. Her gums were swollen, spongy, and bleeding, her tonsils were large, 
and her throat was reddened. There was a systolic murmur over the precordia. The 
lungs were normal. The abdomen was lax. The edge of the liver was felt about one 
inch below the costal border. The spleen was palpable below the border of the ribs 
to the extent of three inches in breadth and two inches in length. There was slight 
glandular enlargement. There were numerous petechia? over the legs and abdomen. 
There were no evidences of rhachitis, no tenderness about the joints, nor swelling over 
the long bones. The temperature was normal. The blood count was as follows : 

Haemoglobin 25 per cent. 

Eed corpuscles 2,024,000 

White corpuscles 87,400 

Lymphocytes 83 per cent. 

Large mononuclear cells 11 " 

Polynuclear neutrophils 5 " 

Eosinophiles 1 " 

There was a slight variation in the size of the red corpuscles, almost none in shape. 
There were no nucleated forms, and no myelocytes. 

A fresh liquid diet, lemon-juice, and stimulants were ordered. The bleeding 
from the gums and bloody discharges continued, as did the purpuric efflorescence. 
The child was not seen again, but died a week later. There was no autopsy. 

In the light of the above history and blood examination there can be no doubt as 
to the correctness of the diagnosis of acute lymphatic leukaemia. If the history can 
be accepted as correct, the onset was acute, there were subcutaneous hemorrhages and 
bleeding from the gums, and the duration of the disease was only two weeks. Owing 
to the circumstances of the child's surroundings, however, it is possible that these 
marked symptoms may have been preceded for a time by others less noticeable. The 
duration of the disease could not have been more than seven weeks. Although the 
glandular enlargement was not marked, that of the spleen was considerable. The 
great bulk of the white corpuscles was made up of lymphocytes. The large mono- 
nuclear forms were also somewhat increased in number. 

The following case of splenic myelogenous leukaemia also came under 
the observation of Morse at the Infants' Hospital : 

A boy, one year old, came to the out-patient department on April 26. His 
parents were Russians, and seemed well and strong. No history of syphilis or tuber- 



886 PEDIATRICS. 

culosis could be obtained. Four other, children were alive and well, two had died of 
some acute disease in Russia. No very definite history of his illness could be obtained. 
He was weaned at three months and had been fed exclusively on condensed milk for 
six months. He had been failing gradually for some months. His abdomen had been 
large for two months, and he had been unable to lie on his left side for one month. He 
had never had epistaxis or hemorrhages from the stomach or bowels. He had never 
had any eruption on the body. He vomited occasionally. His bowels were somewhat 
constipated, and the dejections were light-colored. 

The infant was markedly atrophic and anaemic. The head was large, the forehead 
prominent, and the anterior fontanelle widely open. There was a moderate rosary and 
an enlargement of the epiphyses, with slight bow-legs. There was marked enlarge- 
ment of the glands of the neck, axillae, and groins. The heart and lungs were normal. 
The abdomen was very much enlarged, but contained no fluid. The superficial veins 
were distended. The dulness of the liver began at the upper border of the fifth rib 
in the mammillary line, and the lower border could be felt round and smooth about 
two fingers' breadth below the costal border in the same line. The spleen was very 
much enlarged. It could be felt beneath the costal margin just outside the parasternal 
line, and just outside the umbilicus ; it then extended beyond the middle line, and 
filled up almost the whole left iliac region. The notch could be plainly felt. The 
spleen and abdomen were not at all tender. There were hemorrhagic spots on the skin. 
The blood examination made at this time is given below. 

It was impossible to keep the child under observation, but he was seen again on 
May 28. He had failed rapidly during the month. His skin was very pale with a 
decided yellow tinge, the face, body, and extremities being thickly covered with pur- 
puric spots, varying in size from that of a pin's head to that of a lead-pencil. These spots 
had appeared two days before, at which time he developed a cough, and refused to eat. 
He had no other hemorrhages. The bowels were loose, the dejections were of normal 
color, and there was no vomiting. An examination of the chest showed a broncho- 
pneumonia involving the lower two-thirds of the left lung, and a well-marked bron- 
chitis in the right lung. The heart was normal. The abdomen was rather more dis- 
tended, was not tender, and there was no fluid. There was a slight increase in the size 
of both the liver and spleen. He was almost moribund. 

The usual association of leukaemia with rhachitis was present in this case, the 
leukaemia having probably developed subsequent to the rhachitis. The latter was un- 
doubtedly due to improper food and surroundings, and it seems more reasonable in the 
present state of our knowledge to consider the leukaemia as arising from the same cause 
rather than secondary to the rhachitis. The blood count made on April 26 showed 
2,900,000 red corpuscles and 48,000 white corpuscles per cubic millimetre, giving a 
proportion of 1 to 60. 

The differential count of one thousand white corpuscles on slips dried and stained 
with Ehrlich's triple stain resulted as follows : 

Small lymphocytes 23. 4 per cent. 

Large lymphocytes and transitional forms 8. 1 " 

Myelocytes 21.4 " 

Polynuclear neutrophils 46. 5 " 

Eosinophiles 6 " 

A slip stained with eosin and methylene blue showed numerous mononuclear and 
polynuclear cells with fine granulations which took the eosinophile stain feebly. A 
slip stained with dahlia showed the presence of very few " mastzellen. " Numerous 
partially destroyed cells, both mononuclear and polynuclear, were found. 

There was a very marked poikilocytosis, a moderate number of microcytes, and 
numerous macrocytes, many of these being three times the diameter of a normal red 



THE BLOOD IN INFANCY AND CHILDHOOD. 887 

corpuscle. Many of these forms lacked the normal concavity. Nucleated red cells 
were present in great abundance. No microblasts were seen. Many cells the size of 
normal corpuscles were met with in which the nucleus was smooth, feebly stained, and 
with little nuclear structure, the protoplasm being not quite homogeneous, " wrinkled," 
and stained a reddish violet. These may perhaps be regarded as undeveloped normo- 
blasts. Normoblasts were very abundant, and always with one nucleus, which showed 
a well-developed nuclear structure, and which occasionally presented indentations as if 
division was beginning. The nucleus was rarely in the centre, often on the side, some- 
times half-way out of the cell and occasionally free. The protoplasm was ordinarily 
narrow, but sometimes wide. A few cells were met with from which the nucleus had 
probably escaped. Megaloblasts were quite numerous and presented the same varia- 
tions as the normoblasts. In addition to these a number of large oval cells were seen 
which contained two nuclei, the long diameter of the cells being about four times that 
of the normal red corpuscles. In several of these well-marked karyokinetic figures 
were present ; these variations in the erythrocytes, of course, merely showed a severe 
grade of secondary anaemia. 

ANAEMIA INFANTUM PSEUDO-LEUKAEMICA. 

Synonyms : Anaemia splenica infettiva dei bambini ; anaemia splenica 
[splenomegalie primitive] ; von Jaksch's anaemia. 

Definition. — A condition occurring in infants, usually in the first two 
years of life, characterized by great pallor, considerable enlargement of 
the spleen, moderate enlargement of the liver, a low erythrocyte count, 
usually a moderate leucocytosis, consisting chiefly of an increase of the 
lymphocytes, numerous erythroblasts, low haemoglobin, the absence of 
especial enlargement of the lymph-nodes, and at times accompanied by 
hemorrhages (haematemesis, haematuria, purpura) without any known 
cause. The course of the disease is usually subacute or chronic. 

The term "anaemia infantum pseudo-leukaemica, 1 ' first used by von 
Jaksch in 1889, was originally adopted on the ground that the disease 
was one form of pseudo-leukaemia (Hodgkin's disease). Of late years it 
has been so clearly shown to be different from Hodgkin's disease, in that 
the condition of the spleen is not the same, that the name " pseudo-leu- 
kaemia" is evidently a misnomer and, strictly speaking, should not be 
used in connection with the class of cases under consideration. On the 
other hand, there are as yet so much dispute and such varying opinions 
among those who have carefully studied the group of symptoms which 
are supposed to represent the disease, that there is no other name which 
at present had better be applied to it, since the evidence is very strong 
that no such disease exists apart from severe cases of secondary anaemia 
with enlarged spleen. It is supposed at present to correspond to the so- 
called cases of splenic anaemia in adults. The same difference of opinion 
exists as to the recognition of a splenic anaemia in adults as separate from 
severe cases of secondary anaemia with enlarged spleen. 

Formerly, anaemia infantum pseudo-leukaemica was considered a pri- 
mary disease of the blood, but it was soon differentiated from the dif- 
ferent forms of leukaemia, and later from pseudo-leukaemia (Hodgkin's 
disease). 



888 PEDIATRICS. 

As far back as 1866 a case of a child suffering from a severe form of 
anaemia accompanied by an enlarged spleen was reported by Gretsel. 
Cases have since been described, but in a somewhat indefinite manner, 
and the next important work which appeared on the subject was that of 
Banti in 1883. Banti, however, although believing that anaemia splenica 
was a primary disease of the spleen, considers it also a splenic form of 
pseudo-leukaemia, and it is from Banti's description that the characteristic 
symptoms of the disease are taken as well as the pathology. Following 
Banti, a number of writers have recorded cases which they considered 
to represent the disease splenic anaemia ; but their cases, in the light of 
more modern investigation, are so closely allied in their description to 
those of pseudo-leukaemia that they would at the present time scarcely be 
accepted. 

In 1891 Bruhl published an article on splenic anaemia, and suggested 
the name "splenomegalie primitive." Bruhfs work, however, was very 
much in the same line as Banti's. 

Pathology. — The pathological lesions in a case studied and described 
by Banti were marked fibrous changes in the trabeculae and the follicles 
of the spleen, and a great diminution of the cells. There were many 
large phagocytic cells containing red corpuscles, the bone-marrow Avas 
red and showed a lymphoid condition, but the lymph-nodes were not en- 
larged. The spleen weighed two pounds seven ounces, the liver weighed 
two pounds twelve and one-half ounces. The blood showed a diminu- 
tion of leucocytes, and the red corpuscles were between 2,000,000 and 
3,000,000 per cubic millimetre. The temperature varied for four months, 
sometimes as much as four degrees between morning and evening. There 
was no history of rhachitis, syphilis, or malaria. 

It is very evident that there does not seem to be satisfactory post- 
mortem evidence to warrant a definite pathological condition representing 
the splenic anaemia of infants. There seems to be present in most cases 
a. chronic hyperplasia of the spleen, while in other doubtful cases the 
spleen is not altered. • 

Etiology. — In regard to the etiology of anaemia infantum pseudo-leu- 
kaemica nothing definite has been proved. Although pathological micro- 
organisms, finding conditions favorable for their growth in the spleen, 
may, according to Somma, find their way into the circulation and thus 
produce changes which are represented by certain clinical symptoms, yet 
there is no doubt that the true nature of the disease, if such exists, has 
not yet been discovered. Nothing has ever been found bacteriologically 
to show a direct relation between the micro-organisms present and the 
production of the disease. 

Symptoms. — It is difficult to describe the symptomatology of a disease 
which is so closely identified with cases of secondary anaemia with en- 
larged spleen, and in which the group of symptoms that are supposed 
to represent anaemia infantum pseudo-leukaemica are somewhat diverse. 



THE BLOOD IN INFANCY AND CHILDHOOD. 889 

Both sexes are equally liable to present these symptoms, and the patients 
are usually between the ages of ten and eighteen months ; one has been 
reported of seven and one-half months, and one at three and one-half 
years. The onset of the disease is gradual, the nutrition is poor ; there 
are considerable emaciation, a waxy tint of the skin, at times hemorrhages 
from the mucous membranes and the skin, a much enlarged spleen, and 
a moderately enlarged liver. There is no tenderness over the bones, and 
there are often a venous bruit in the neck and functional cardiac murmurs. 
The blood shows the characteristics of a secondary anaemia of varying 
intensity, — that is,, a diminished number of erythrocytes, low haemoglobin, 
variations in the size and shape of the erythrocytes and in the number 
of erythroblasts. The leucocytes are not characteristic, being markedly 
increased in some cases and in normal proportion in others. The lympho- 
cytosis, reported by many writers, may occur under any condition, giving 
rise to an increased number of white cells. 

Diagnosis. — There seems to be no doubt that anaemia infantum pseudo- 
leukaemica and anaemia splenica infettiva are the same condition, and, as 
there does not seem to be reason for believing that the spleen is primarily 
affected in either of them, they need not be differentiated one from the 
other. The differential diagnosis should first be made from leukaemia and 
pseudo-leukaemia. The proportionately low leucocytosis and the absence 
of either a general lymphatic enlargement or an excess of myelocytes in 
the blood would differentiate it from the former, while the absence of 
enlarged lymph-nodes would exclude pseudo-leukaemia. As there are so 
few cases in which a thorough and reliable examination of the organs has 
been made in which rhachitis was not present, the diagnosis between 
rhachitis with enlarged spleen and secondary anaemia, and this supposed 
especial group of symptoms, would be impossible. 

We know that in infants the same blood changes which have been 
mentioned above often occur in connection with an enlarged spleen in 
the course of or following any disease of nutrition. "We are therefore in 
the position of attempting to make a diagnosis between two conditions 
which are practically the same. In making a diagnosis we should limit 
the term anaemia infantum pseudo-leukaemica to those cases in which no 
cause for secondary anaemia can be found, and in which the clinical 
symptoms and changes in the blood already described are present. 

Prognosis. — The prognosis varies according to the extent and serious 
nature of the cause which produces the condition. The symptoms run 
an essentially subacute or chronic course ; the large size of the spleen 
does not necessarily imply a fatal ending. When, however, secondary 
changes in the blood have occurred to such an extent as to warrant the 
diagnosis of a severe form of anaemia, and when a spleen of considerable 
size is detected in connection with these blood changes, the prognosis is 
very bad, as the infants usually die. 

Treatment. — What has just been said of the prognosis in this class of 



890 PEDIATRICS. 

cases may also be said of the treatment, which is, in fact, that of a 
case of secondary anaemia, and depends upon what is most reasonably 
supposed to be causing the condition that is present. This may be 
malaria, rhachitis, gastro-enteric disease, or some unknown cause which, 
simply representing the conditions of anaemia, calls for the usual treat- 
ment of arsenic, iron, proper food, and hygiene, the detailed description 
of which will be found under the heading of the especial disease with 
which the symptoms are associated. 

PRIMARY ANAEMIAS. 

Pernicious Anaemia. — This is the most severe form of primary anae- 
mias, and is characterized by quite constant changes in the blood, usually 
developing without evident cause, and a progressive course, leading to a 
fatal termination in the majority of cases. 

Etiology. — This disease is much less frequent in children than in adults, 
the proportion of cases being about one to seventeen. It is less common 
in infancy than in later childhood. Of twenty-five reported cases, four 
were between the ages of three months and two years, four between 
three and five years, eight between six and ten years, and nine between 
ten and fifteen years. In the majority of cases no definite cause has been 
discovered. In some, the following etiological factors have been noted: 
syphilis, severe rhachitis, especially with splenic, enlargement, and intesti- 
nal parasites, such as taenia, ankylostoma, and bothryocephalus. The 
best theory for the explanation of the condition seems to be that of a 
toxic haemolysis. There are evidences of increased destruction of blood- 
cells in the urine, blood, and tissues, and also of a compensating hyper- 
trophy in the blood-forming organs. There is considerable evidence that 
the alimentary tract is the source of the unknown toxins causing hae- 
molysis. 

Pathology. — The body is not often emaciated. The skin usually 
shows a lemon-yellow tint. There is marked anaemia of the organs at 
times, with many capillary hemorrhages into the organs and skin. The 
heart is large and flabby, and shows intense fatty degeneration. The liver 
is fatty and sometimes enlarged. The kidneys and blood-vessels show 
fatty changes. One of the most characteristic features is a deposit of iron 
in the liver tissue and often in the intestinal mucosa. The spleen is hard 
and somewhat increased in size as a result of overgrowth of the fibrous 
tissue of the pulp. Some of the lymph-nodes are often enlarged. The 
bone-marrow is "splenified," — that is, returned to its embryonic state. 

Symptoms. — Blood. — The red corpuscles are much diminished, usually 
to one million, sometimes even to five hundred thousand. The haemo- 
globin is diminished per bulk of the blood, often to twenty-five or thirty 
per cent., rarely to twelve or fifteen per cent., but owing to the greater 
reduction of red cells it is often relatively increased per corpuscle (the 
color index is high and sometimes greater than normal). This is exactly 



THE BLOOD IN INFANCY AND CHILDHOOD. #91 

the opposite condition to that which occurs in chlorosis. The red cells 
show great variation in shape and size, many oval or rod-shaped or irreg- 
ular corpuscles are present, which take stains in an uneven way. A 
majority of the red cells are larger than normal (megalocytes). Many 
nucleated red cells are present, both of normal size (normoblasts) and of 
larger size (megaloblasts). The megaloblasts are the more numerous of 
the two. Many of the nuclei are found in a process of division (karyo- 
kinesis). The leucocytes are normal in number, or somewhat diminished, 
— eight thousand to four thousand. In the more severe cases there is fre- 
quently a relative increase of the lymphocytes with a corresponding dimi- 
nution of_the polynuclear cells. A few myelocytes are not infrequently 
found. 

The general symptoms are those of severe anaemia, increasing pallor 
and prostration,' usually without emaciation. The onset is insidious, and 
the clinical course does not differ from that of adults. There is fre- 
quently more or less gastro-enteric disturbance, vomiting, nausea, or 
dyspnoea. Hemorrhages occur into the skin or from the nasal and other 
mucous membranes. . (Edema often appears in the dependent portions of 
the skin, less frequently in the cavities of the body. Haemic murmurs are 
usually heard in the cardiac region. The pulse is full and soft. It is to 
be noted that haemic murmurs are less frequent in the anaemia of infants 
than in that of adults. The urine is scanty and of low specific gravity. 
The temperature is variable ; at times it may be normal, and at others an 
irregular pyrexia may run for a considerable period. The course is a 
chronic one, but varies in length. The disease may be completely devel- 
oped in some cases in two or three months, and in others only after ten 
or twelve months. In most instances it progresses steadily to a fatal 
termination. 

Diagnosis. — The diagnosis from other forms of anaemia is made chiefly 
by the blood examination. The characteristic features are : 

(1) Great diminution in the number of reel cells. 

(2) Relative increase of haemoglobin per corpuscle. — high-color index. 

(3) Irregularity of distribution of haemoglobin in the red cells. 

(-1) Marked irregularity in form and size, and a general increase in 
size of the red cells. 

(5) An excess of megaloblasts over normoblasts. 

(6) A normal or diminished leucocyte count. 

Prognosis. — The prognosis is almost absolutely fatal, except in those 
cases associated with intestinal parasites or rhachitis, although lately, 
when arsenic has been given, the proportion of recoveries has increased. 
The blood examination is a valuable index to the prognosis. The pres- 
ence of many normoblasts is hopeful, pointing to a regeneration of the 
bone-marrow. The presence of a large excess of megaloblasts indicates 
a more malignant case. 

Treatment. — Arsenic is more useful than iron in this form of anaemia. 



892 PEDIATRICS. 

It is usually well borne, and should be given in small doses, gradually 
increased to the limit of tolerance. A child of ten years can usually 
take 2 c.c. (30 drops) of Fowler's solution in the twenty-four hours. 
Arsenic may also be given in pill form. Active exercise should be pro- 
hibited and replaced by massage, which is of great value and never to be 
neglected. Rest in bed, either absolute or for the greater part of the 
time, is essential. Small, frequent, and regular meals should be given, of 
light, nutritious food. Bone-marrow in the form of a glycerin extract has 
been recommended, but has thus far proved of doubtful value. The free 
administration of oxygen day and night for several weeks is worthy of 
trial, if expense is not to be considered. I have had one case in which 
the red cells had fallen to 1,088,000 and the haemoglobin to 20 per cent. 
Rapid improvement in the blood followed this treatment when carried 
out for over four weeks, and the blood eventually became normal. The 
case is still under observation. 

The following case, probably one of pernicious anaemia, though the 
result of the blood examination is not conclusive, was seen in consulta- 
tion with Dr. C. P. Putnam. 

The infant was healthy at birth, and up to the time of its present sickness had never 
had any disease. For several months it had grown progressively pale, its appetite had 
decidedly lessened, it had not lost materially in weight but had grown weak, and its 
mental hebetude had been so noticeable that a suspicion had arisen that it was lacking 
in cerebral development. On inspection the infant seemed moderately fat, but the 
muscles were soft and the skin was of an extremely pale and waxen tinge. It was 
evidently very weak. On physical examination nothing abnormal was detected about 
the head, thorax, or abdomen. All the organs seemed to be of natural size. The 
blood examination showed the following : 

Red corpuscles 1,571,000 

Haemoglobin 22 per cent. 

White corpuscles 19,100 

Small mononuclear 42 per cent. 

Large mononuclear 18 " 

Poly nuclear 40 " 

The child died a few days later without showing any other symptoms. 

Chlorosis. — Chlorosis is a primary anaemia of unknown cause, char- 
acterized by a marked diminution in the haemoglobin in the blood with- 
out a corresponding loss in the number of red cells. It is not a dis- 
ease of infancy or of young children, but appears in girls, especially 
blondes, between the ages of twelve and seventeen years. The essen- 
tial cause is unknown. It is chiefly seen in overworked girls living amid 
poor hygienic surroundings. Psychical disturbance, such as grief, worry, 
and fright, are important factors. Clark has stated that the condition is 
a copraemia due to toxic absorption (ptomaines and leucomaines) from the 
intestine. 



THE BLOOD IN INFANCY AND CHILDHOOD. 893 

Pathology. — Chlorosis is rarely fatal. In some cases hypoplasia of 
the heart, large vessels, ovaries, and uterus have been found, also con- 
siderable fatty degeneration of the heart and of the intima of the vessels. 
Gastric ulcer has been occasionally associated with it. 

Symptoms. — The essential change in the blood is a marked loss, in the 
individual red corpuscle, of the haemoglobin, which is often only 40 per 
cent., and in severe cases below 30 per cent. The specific gravity of the 
blood may be reduced to 1025, although usually not below 1035. The 
red cells in a few cases are normal ; in the majority they are reduced to 
4,000,000 or may be even lower. The red corpuscles may be very irregu- 
lar in size and shape in severe cases, and may have an average size which is 
less than normal. Nucleated red cells are often seen, usually normoblasts, 
rarely megaloblasts. Leucocytosis is not present. The onset of chlorosis 
is gradual, the course chronic, and relapses are common. The symptoms 
are those of a simple anaemia. The patient complains of shortness of 
breath on exertion, and attacks of palpitation and syncope are common. 
The appetite is poor or perverted, and there is a craving for unusual and 
indigestible articles of diet. Gastric hyperacidity is often present, and 
constipation almost always. Enteroptosis is not uncommon. The patient 
frequently complains of headache or neuralgic pains. Hysterical manifes- 
tations may occur. The menstrual function is often disturbed ; the flow 
is scanty, irregular, and sometimes painful. The patient is usually plump 
and soft, and the skin has a peculiar greenish-yellow tint which gives the 
disease its popular name of "green sickness." Systolic murmurs are 
frequently heard over the heart in the pulmonary or mitral region, and 
also a venous hum, the "bruit cle diable, 1 ' in the veins of the neck. 
Palpitation is occasionally seen in the jugular veins. There is a tendency 
to venous thrombosis, which most often occurs in the femoral veins. 
The pulse is full and soft. Occasionally there is some puffiness of the 
face, and often oedema of the ankles. The spleen may be slightly en- 
larged. The urine rarely contains a slight trace of albumin. Gastric 
ulcer sometimes occurs as a complication. 

Diagnosis. — The age and sex of the patient, the well-nourished con- 
dition, the pearly sclerotics, the color of the skin, and the character of 
the blood form a striking clinical picture which easily distinguishes chlo- 
rosis from other forms of anaemia. 

Prognosis. — The prognosis is almost always good. The disease often 
lasts a year and relapses are common. Chlorosis is rarely fatal, except 
when complicated by tuberculosis or gastric ulcer. 

Treatment. — There are few therapeutic measures in medicine more 
satisfactory than the use of iron in chlorosis. In infants the iron can be 
given in the form of the saccharated carbonate, 0.12, 0.18, or 0.24 
gramme (2, 3, or 4 grains), or of the tartrate of iron and potash. Lactate 
of iron can also be given to older individuals in closes of 0.06 to 0.12 
gramme (1 to 2 grains), gradually increased to 0.24 to 0.36 gramme (4 to 



894 PEDIATRICS. 

6 grains), three times a day. The administration of iron is usually fol- 
lowed by a rapid increase in the number of red cells to the normal or 
even above it. The haemoglobin, however, increases more slowly. When 
iron is not tolerated, arsenic can be given in the form of Fowler's solution. 
When the iron causes constipation, it should be accompanied or followed 
with a saline or with some preparation of rhubarb. A change of scene is 
often beneficial, and later an out-of-door life and moderate exercise. 

SECONDARY ANAEMIAS. 

Under the title of secondary anaemia we include anaemia resulting 
from many kinds of pathological processes in the body Avhich occur out- 
side of the blood-forming organs. 

Etiology.— Almost every disease of any organ in the body may produce 
a secondary anaemia, and it is of high or low grade according to the severity 
of the disease. There are two important factors in the process, — namely, 
an insufficient production of blood on account of poor food or poor assimi- 
lation, and the increased destruction of blood as it occurs in many wasting 
diseases. The anaemia of infancy may be either congenital or acquired. 
The congenital forms are inherited from delicate or anaemic parents, or 
from a mother who has suffered with syphilis, tuberculosis, or malaria 
during her pregnancy. Of the acquired anaemias, a comparatively small 
number of cases occur after hemorrhage, as in epistaxis, haemophilia, 
purpura, or scorbutus. The more frequent causes of anaemia in infants 
and young children are disturbances of digestion and assimilation, such 
as are represented by inanition and chronic indigestion resulting from im- 
proper quantity and quality of the food. Anaemia may also result from 
chronic diarrhoea, ileo-colitis, constitutional conditions resulting from 
unhygienic surroundings, bad air, close confinement, general debility, 
rhachitis, and also from malignant disease. Another cause is found in 
the drain on the albumin of the blood occurring in chronic suppuration, 
nephritis, and effusions, and still another in the toxaemia produced by 
mineral poisons, such as arsenic or lead, or by infectious diseases, such as 
septicaemia, diphtheria, scarlet fever, syphilis, malaria, and tuberculosis. 

Symptoms. — Luzet divides the anaemias of infancy into two classes, — 
those with splenic enlargement and those without, — and states that the 
first form is more severe, and that the blood in these cases contains a 
larger number of nucleated red cells. This classification is not a very 
satisfactory one, for we find very severe anaemias without splenic enlarge- 
ment, and also marked splenic hypertrophy in many cases of mild anae- 
mia. Monti and Berggriin propose another classification, which is more 
satisfactory. They divide all secondary anaemias into four classes : 

(1) Mild anaemias. 

(2) Mild anosmias with leucocytosis. 

(3) Severe ancemias. 

(4) Severe anosmias with leucocytosis. 



THE BLOOD IN INFANCY AND CHILDHOOD. 895 

In the mild anaemias there is a moderate diminution in the specific 
gravity of the blood, in the haemoglobin, and in the red cells, and the latter 
show practically no changes in size and in shape. In the severe anaemias 
there is a marked diminution in the specific gravity, haemoglobin, and red 
cells, and the latter show considerable changes in size and form (poikilo- 
cytes, normoblasts, megaloblasts). The difference between these two types 
is one of degree. Either form may be associated with leucocytosis, and the 
forms with leucocytosis are much more common than those without, and 
are almost invariably the more severe. In all but the mild anaemias with- 
out leucocytosis the spleen may be enlarged. The number of red cells 
varies from normal, in the mild cases, to two million in the severe, the spe- 
cific gravity from 1056 to 1035, the haemoglobin from eighty to thirty per 
cent., the white count from normal to sixty thousand. In secondary anae- 
mia the reduction in the total amount of haemoglobin is almost always 
proportionately greater than in the corpuscles (chlor-anaemia). In gen- 
eral, the more severe the anaemia the lower is the specific gravity of the 
blood, the greater is the variation in size and shape of the red cells (poi- 
kilocytosis), and the more numerous the nucleated red cells. These last 
are much more abundant in children than in adults with a corresponding 
grade of anaemia. In these cases we have the familiar clinical picture of 
pallor, soft muscles, digestive disturbance, fretfulness, headaches, insom- 
nia, fatigue, and breathlessness on exertion. Occasionally epistaxis is 
associated with the signs and symptoms of the primary disease. Haemic 
murmurs are usually heard over the heart and the vessels of the neck. 
(Edema is more common in older children than in adults. 

Diagnosis. — In the diagnosis of these anaemias the recognition of the 
cause is very important. The diagnosis from the so-called primary 
anaemias is sometimes quite simple, by means of the blood examination, 
especially in older children ; in young children it is often very difficult, as 
a result of certain factors which have already been mentioned, — namely, 
the frequency of splenic hypertrophy in all forms of anaemia, the ease 
with which a leucocytosis is developed, the frequent occurrence of abun- 
dant myelocytes and nucleated red cells, and the fatality of all severe 
anaemias in children ; in short, the exaggeration of all blood changes in 
infants and young children. 

Prognosis. — The prognosis depends on the age, cause, and condition 
of the blood. The course of the anaemia is usually several months. 
Traumatic cases, which are rare in childhood, are the most benign, since 
in these cases the blood is readily restored to its normal condition. The 
group of cases which depend on toxaemia or a drain of the albumin of 
the blood, such as in suppuration, fever, or from other causes, are diffi- 
cult to treat, unless the cause can be removed. The severe cases may 
develop into a pernicious anaemia or a leukaemia, but death occurs more 
commonly as a result of some complicating disease rather than of the 
anaemia itself. The prognosis is naturally less favorable in cases in which 



896 PEDIATRICS. 

the haemoglobin is reduced to 30 per cent, or less, and the red cells to 
half their normal number, with marked poikilocytosis. The cases with 
leucocytosis are graver than those without. 

Treatment. — It is of the first importance to treat the cause, as, for in- 
stance, cases which are secondary to malaria, syphilis, or rhachitis ; or to 
remove the cause, if possible, in cases of inhalation or ingestion of poisons, 
such as arsenic, impure air, or improper food. The general treatment in 
infants and young children is usually far more important than the use of 
drugs. The treatment of infants is, above all, prophylactic, with the object 
of protecting them from such unfavorable influences as may interfere with 
their health and proper development. The question of feeding or of 
adapting the food to the child's digestion is of great importance, and 
fresh air, in the country if possible, is indicated. The best forms of iron 
to be used in the secondary anaemias of infants and young children are 
the saccharated carbonate and the tartrate of iron and potash. At times 
arsenic in the form of Fowler's solution can be used. 

The following case of secondary anaemia, occurred in a child suffer- 
ing from rhachitis with splenic enlargement, and is represented in Fig. 
86, page 337. 

The child was three years old and fairly well nourished. It had, however, en- 
larged epiphyses, a rhachitic rosary, a square, rhachitic head, and marked bowing of the 
legs. On physical examination there was no indication of enlargement of the liver or 
glands. The spleen was very much enlarged, its outline showing the notch as indi- 
cated in black. The blood examination gave the following result : 

Eed corpuscles 2,686,250 

Haemoglobin 35 per cent. 

White corpuscles 13,000 

There were poikilocytosis and a marked pallor of the corpuscles. (Wentworth.) 

The following is a case of secondary anaemia occurring in connection 
with congenital syphilis with enlarged spleen, and is represented in Fig. 
121, page 536. 

The infant was three months old, and was nursed by its mother. It was healthy 
at birth, and remained so until three months old, when it showed marked syphilitic 
symptoms, which later became very characteristic. It was faiily well nourished. The 
skin was of the waxen pallor characteristic of the higher grades of grave anaemia. 
There was a moderate enlargement of the liver, which, on palpation, was found to be 
hard and somewhat tender. The inguinal lymph-nodes were slightly enlarged. The 
post-aural lymph-nodes were enlarged. The spleen was much enlarged, and extended 
from the fifth rib to the left inguinal region. It had a peculiar tongue-shaped outline, 
and was hard but not tender. There were no other glandular enlargements. An ex- 
amination of the blood gave the following result : 

Nov. 17. Nov. 20. 

Red corpuscles 3,387,000 3,300,000 

Haemoglobin 47 per cent. 45 per cent 

"White corpuscles 20,000 20,000 

There was considerable variation in the size of the red blood-corpuscles, which were 
pale and showed a moderate degree of poikilocytosis ; there were also some microcytes 



THE LYMPH-NODES IN INFANCY AND CHILDHOOD. 897 

and megalocytes. The mononuclear elements predominated. The eosinophiles were 
not numerous. (Went worth.) 

THE LYMPH-NODES. 

Pathological conditions of the lymph-nodes may be primary or second- 
ary. The primary forms are represented by simple inflammations of the 
lymph-nodes (simple acute adenitis), caused by the colon bacillus and other 
micro-organisms from the mouth and gastro-enteric tract. Among these 
organisms the tubercle bacillus holds an especially prominent place. 

The secondary forms are due to tuberculosis, syphilis, and anaemia, and 
have been considered under these diseases. 

SIMPLE ACUTE ADENITIS. 

Etiology. — The place of invasion of the infection which produces 
simple acute adenitis is either the skin or the mucous membranes, the 
bacteria or their toxines reaching the nodes by means of the lymphatics. 

The cervical nodes may be infected from a number of sources, such as 
irritation or lesions of the scalp, the ears, eyes, nose, throat, gums, or 
teeth. 

The bronchial nodes may be infected from inflammation of the trachea, 
bronchi, and lung tissue, such as in bronchitis and pneumonia. 

The mesenteric nodes may be infected from such conditions of the 
intestine as cholera infantum and ileo-colitis. 

Axillary adenitis may result from lesions of the arm, such as are pro- 
duced by vaccination ; and in a like manner inguinal adenitis my follow 
lesions of the foot and leg or inflammatory conditions of the genitals. 

Acute adenitis is also a frequent complication of the acute infectious 
diseases, especially scarlet fever, measles, and diphtheria. 

Infection and enlargement of the superficial nodes demand special 
consideration, as they are of frequent occurrence and are easily detected. 
Inflammation of the deeper nodes had best be described in connection 
with the organs with which they are especially connected, as their clinical 
recognition is so often impossible. Thus, when there is an acute inflam- 
mation of the bronchial or mesenteric nodes, general symptoms of cough 
and diarrhoea are usually referred to the lung or intestine, unless, as may 
occur in extreme cases, distinct symptoms of pressure in the thorax or 
palpable tumors in the abdomen are present. 

Pathology. — The affected nodes show a condition of acute congestion 
and hyperplasia, but do not become cheesy, except when the infection is 
tubercular. The process may end in suppuration or resolution, according 
to the severity of the infection. Suppuration is especially frequent in 
infants and young children, and the pus usually begins in the second or 
third week from the onset of the morbid process. 

Periglandular cellulitis is common when the inflammation is acute 
and severe. 



898 PEDIATRICS. 

Symptoms. — There is very little or no constitutional disturbance in 
non-suppurative adenitis. The nodes are enlarged, hard, and tender, and 
if periadenitis is present, immovable. Lymphangitis and fever may be 
present. The swelling usually subsides slowly after a few months. 

In the suppurative cases there may be quite severe general as well as 
local disturbance, with fever and chills. The nodes, if opened, usually 
heal quickly and completely. 

Diagnosis. — The diagnosis of simple acute adenitis of the superficial 
lymph-nodes is not difficult, if some local condition can be found to ac- 
count for it. The differential diagnosis from tubercular adenitis is de- 
scribed under tubercular lymph-nodes, on page 390. 

Treatment. — The first effort in undertaking the treatment of these 
cases should be to seek for and remove the peripheral source of irritation 
Avhich exists in most cases. Decayed teeth should be extracted, eczema 
of the scalp should be treated, and in all cases as much as possible should 
be done to diminish any irritation in the area of surface drained by the 
cervical lymphatics. During the active stage of cervical adenitis it is 
better not to make any application to the glands, but to treat any general 
disturbances, such as anaemia or debility, which may be present. 

If the glands suppurate, they should be freely opened, when the pus 
has pointed, and be treated with antiseptics. If there is much broken- 
down tissue, the abscess cavity should be curetted. 

SIMPLE CHRONIC ADENITIS. 

In cases of simple chronic adenitis the enlargement of the nodes is 
due to a simple hyperplasia. Both the superficial and deep nodes may 
be affected, but for the same reason stated in speaking of acute adenitis, 
the affections of the superficial nodes only will be spoken of here. 

Chronic adenitis is much less common than acute adenitis, and rarely 
occurs except in infants and young children. It usually occurs as a re- 
sult of several attacks of acute inflammations or of chronic affections of 
the skin or mucous membranes. The nodes are usually more uniformly 
enlarged, but the swelling is not so great as in either the acute or tuber- 
cular forms. There is no constitutional disturbance referable to the nodes 
themselves. The course is slow, and may extend over a period of months 
or years. There may be an associated hypertrophy of lymphoid tissue 
elsewhere, as in that of the tonsils and in adenoids. 

Diagnosis. — From Tubercular Adenitis. — Simple chronic adenitis is 
most frequently confounded with tuberculosis. The chief points in the 
differential diagnosis are found in its usual occurrence in very young chil- 
dren at an age when glandular tuberculosis is uncommon, in the evidence 
of a primary cause to which the chronic adenitis is secondary, in the ab- 
sence of caseation, suppuration, and periadenitis, and, finally, in the 
greater influence of general tonic treatment. 

From Hodgkin's Disease. — Simple chronic adenitis is distinguished less 



THE DUCTLESS GLANDS IN INFANCY AND CHILDHOOD. 



899 



easily from Hodgkin's disease, but in the latter the enlargement of the 
nodes is greater and more generally distributed, the secondary anaemia is 
more pronounced, and the disease is of rare occurrence as compared with 
chronic adenitis. 

From Syphilitic Adenitis. — The absence of other signs of late syphilis, 
such as are described on page 536, and the negative results of anti-syphi- 
litic treatment make the exclusion of syphilitic adenitis comparatively 
easy. 

From New Growths. — New growths are usually to be distinguished by 
their greater size and by the absence 
of an exciting cause, more positively 
by the microscopic examination of a 
portion of the node excised for the 
purpose of diagnosis. 

Treatment. — In the treatment of 
simple chronic adenitis, the primary 
exciting cause should be removed if 
possible. Local applications should 
be avoided, and general tonic treat- 
ment instituted by means of cod-liver 
oil, Fowler's solution, the iodide of 
iron, good food, and out-of-door life. 
If these measures fail, the treatment 
becomes surgical. 

Fig. 185 represents a case of 
chronic cervical adenitis in which the 
cervical lymph-nodes were enlarged to 

such an extent that they had become a deformity. Nothing else abnormal 
nor any symptom of tuberculosis was discovered about the child. 

DISEASES. OF THE THYROID GLAND. 

The function of the thyroid gland is not definitely known, but it is 
generally believed to secrete certain nutritive or antitoxic substances 
which are necessary for normal metabolism. Disturbance in the func- 
tion of the gland, resulting either in hypersecretion or diminished secre- 
tion, gives rise to different types of symptoms. Such disturbances may 
be produced by simple hyperemia, hypertrophy, atrophy, new growths, or 
as a result of excision of the gland. 




Chronic cervical adenitis. 



GOITRE (Bronchocele). 
Enlargement of the thyroid gland is commonly called goitre. True 
goitre consists in the enlargement of the old and in the formation of new 
alveoli, in the cells of which a greater or less amount of colloid degenera- 
tion takes place. The colloid abnormalities of goitre are rarely present 
in children (Rex), in whom the thyroid enlargement seems to be little 



900 



PEDIATRICS. 



Fig. 186. 



more than a continuation of the natural growth and a true hypertrophy 
or an excessive development of normal tissue. Usually the enlargement 
of the gland is the only symptom. Infants have been born with an en- 
larged thyroid. 

The disease is endemic in Switzerland, in certain parts of France and 
Italy, and in Michigan. The enlargement may be purely vascular (hyper- 
emia of the thyroid), parenchymatous, or cystic. In places in which the 
disease is endemic the cause in many cases seems to be due to the 
drinking-water. It has a certain relation to the congenital form of myxce- 
dema, or cretinism, the nature of which has not been fully determined. 
A woman with goitre may, on removal to a place in which the disease is 
endemic, give birth to a cretin. Although a simple goitre generally gives 
rise to no symptoms other than those of pressure, symptoms of myx- 
cedema may develop. The inference is that this complication is due to 
the interference with the function of the gland, as a result of which its 
secretions are either diminished or entirely checked. When myxcedema 
does not develop, as it does not in the majority of cases of goitre, we 
may account for the fact on the supposition that the enlargement of the 
gland has not affected its function as a secreting organ. 

Hypersemia of the Thyroid. — 
Between the ages of twelve and fifteen 
years in girls, about at the time of 
puberty, an active hyperemia of the 
rich vascular tissue of the thyroid oc- 
curs, leading at times to a consider- 
able and rapid enlargement of the 
gland. Anaemia, especially chlorosis, 
palpitation, accelerated pulse, and 
various nervous symptoms are not 
uncommon at this same period, and 
when noted in connection with the 
hypersemia and enlargement of the 
thyroid may give rise to the belief 
that the condition is the beginning of 
the much more serious disease ex- 
ophthalmic goitre. This enlargement 
of the thyroid does not usually persist, 
however, the disease generally subsiding under appropriate treatment of 
the anaemia and galvanization of the thyroid, and the diagnosis is readily 
made. 

Fig. 186 represents one of these physiological disturbances in the 
thyroid due to an active hypersemia. 




Hypersemia 



the thyroid gland. 
13 years old. 



The girl, thirteen years old, was first noticed to have a swelling of the thyroid gland 
two or three weeks before coming under observation. The swelling was at that time 



THE DUCTLESS GLANDS IN INFANCY AND CHILDHOOD. 901 

becoming more prominent. The catamenia had not appeared. The girl was well 
and strong, but was more fretful and capricious than seemed consistent with her usual 
temperament. The tumor was elastic, did not fluctuate, and was neither red nor tender. 

MYXOEDEMA. 

Myxoedema is a constitutional affection, generally associated with 
atrophy of the thyroid gland, and characterized clinically by a thickened 
and dry condition of the skin and subcutaneous tissues, and later by 
mental failure. 

The symptoms are supposed to be caused by a diminished or total lack 
of secretion of the thyroid gland due to its atrophic condition (athyrea). 
The disease may be congenital or acquired. Acquired myxoedema is seen 
most commonly in adults, and will not be especially described. Operative 
myxoedema, or cachexia strumipriva, is a condition closely resembling ac- 
quired myxoedema of adults, and follows the removal of the thyroid gland 
by operation. The form of myxoedema which is especially related to in- 
fants and children is that which is known as cretinism, or congenital 
myxoedema. 

Cretinism (congenital myxoedema). — Two classes of cases are recog- 
nized : one, known as endemic cretinism, represented by the cretins of 
Switzerland, Italy, France, of the great lakes (Michigan) of America, and 
of other places ; and a second class, known as sporadic cretinism, repre- 
sented by individual cases which may be met with anywhere. 

Pathology. — There may be a congenital absence of the thyroid gland, 
or atrophy may occur, as after one of the specific infectious diseases. 

The head in sporadic cretinism is usually brachycephalic, — that is, it is 
contracted in its antero-posterior diameter. Virchow was the first to 
observe in these cases a premature ossification of the spheno-basilar bone. 
The sphenoid and basi-occipital bones should remain separate until about 
the fifteenth year, and their early ossification explains, according to 
Virchow, the changes which take place in the form of the cretin skull and 
face. 

Occasionally the thyroid gland in a cretin is enlarged, as in a simple 
goitre, but its function is absent, as shown by the symptoms characteristic 
of athyrea. 

There are certain characteristics of the bones in cretins, consisting of 
an enormous overgrowth of cartilage, an arrest of growth at the distal 
ends of the bones, and a premature ossification of the shaft. Fig. 82, II., 
page 329, represents a section of the tibia of a sporadic cretin child. It 
is distinguished anatomically by an almost entire absence of the zone of 
proliferation (Whitney). 

Symptoms. — In sporadic cretinism the symptoms of the disease usually 
develop in the first year of life, sometimes not until the second or third 
year or even later. The body is dwarfed. The anterior fontanelle re- 
mains open until the eighth or tenth year. The face is full, stolid, and 
expressionless. The nose is broad and flat ; the eyes are small, wide 



902 PEDIATRICS. 

apart and half closed by the swollen lids. The mouth is open, the lips 
are thick, and the tongue protrudes. The cheeks are swollen and bloated. 
The hair is coarse and straight, and usually light-colored. The teeth are 
rough, irregular, and liable to early decay. The voice is rough and harsh. 
Spinal curvature is apt to be present, and is much more apt to be in the 
nature of a lordosis than of a kyphosis. The extremities are short and 
stunted, and the hands and feet are pudgy. Normally at birth the legs 
are about 43 per cent, of the total height, and at four or five years about 
50 per cent. In cretins this percentage is lessened to between 35 and 
40 per cent, of the total length. The skin is everywhere dry, thick, and 
bloated, and does not pit on pressure. Perspiration is scanty. The 
muscles are weak and flabby, and the motions slow and clumsy. The 
neck is short and thick, and the abdomen large and pendulous. Fatty 
tumors are not infrequently to be found in the supra-clavicular regions. 
The genitals are small and undeveloped. Habitual constipation is com- 
mon. The temperature is frequently subnormal. The temperament of 
cretins is placid, and their expression stupid or even idiotic. Their mental 
and physical development is very backward ; they learn to talk late or not 
at all. 

Diagnosis. — The appearance of a cretin is so characteristic that a diag- 
nosis is rarely difficult. Foetal or early and severe rhachitis may give rise 
to marked deformities suggestive of cretinism, but do not show the other 
physical signs and the mental symptoms. 

Treatment. — The recognized specific treatment of all forms of myxe- 
dema is the administration of preparations of the thyroid gland. The 
success of this method is one of the most brilliant triumphs of modern 
experimental medicine. The results of treatment for several months are 
remarkable, as the entire appearance of the child is changed. The thick- 
ening of the skin disappears, the idiotic expression is lost, and the growth 
and development of both body and mind progress rapidly. A large num- 
ber of cases have been reported illustrating the effects of the thyroid treat- 
ment. The question whether the improvement will continue indefinitely 
and go on to complete and permanent recovery is one for the future to 
decide. 

The dried powdered gland or the glycerin extract are the most conve- 
nient means of administration. 

The dried thyroid extract may be given in tablet form in doses of 0.03 
to 0.06 gramme (J to 1 grain) three times daily. Unpleasant effects from 
the treatment are rare. A decided rise in the temperature indicates that 
the use of the thyroid extract should be suspended for a time. The 
earlier the treatment is begun the better are the results obtained. When 
the normal condition of the body has been restored by the use of fairly 
large doses of the thyroid extract, it will be necessary to continue the 
treatment indefinitely with doses small enough to maintain the equilibrium 
of the metabolism of the body. It should be remembered that these 



THE DUCTLESS GLANDS IX INFANCY AND CHILDHOOD. 



903 



children are especially susceptible to cold, and should be kept in an even 
temperature or taken to a warm climate during the winter. 
187 represents a case of sporadic cretinism. 



Fig. 



The child was a girl, five and a half years old. Her parents were healthy Ameri- 
cans, not blood relations, and did not have goitre. She was born after a severe labor ; 
it was a head presentation, and no instruments were used. Nothing especially abnormal 
was noticed about her until the twelfth month, 
when she did not seem so bright as is usual at 
that age. When four years old she was 
brought to the hospital. She could not speak, 
and her mental condition was much enfeebled. 
She could scarcely stand, and looked as though 
she were about one and a half years old. 
She had never had any convulsions, but had 
always had incontinence of urine and of 
faeces. When seen a year later she appeared 
to be in good general condition, but her mus- 
cles were large and flabby and she had not 
improved mentally. The circumference of 
her head was 46.05 cm. (18-}- inches). The 
measurement from the occiput to the root of the 
nose was 34.4 cm. (13J inches), and across the 
head from external meatus to external meatus 
29.3 cm. (11| inches). The circumference of 
the thorax was 40.3 cm. (15f inches). There 
were no irregularities about her head. The 
forehead was overhanging, and this was ren- 
dered more striking on account of the sunken 
bridge of the nose. The lips were thick, and 
the tongue, which seemed enlarged, was pro- 
truded between them. The hearing was said to 
be good, and the sight was good. She had been 
able to sit alone since she was one year old, 
but could stand only with support, and could 
not walk. She was bow-legged, and the bones 
were somewhat enlarged about the epiphyses. 
The hands and feet were large and puffy, 
but did not pit. The feet were bright red, the hands less so. The trunk was stout and 
thick; the spine was straight; the lungs and heart were normal, and nothing abnormal 
could be detected about the abdomen except an umbilical hernia. The tendon reflexes 
were normal. Sensation was normal. The thyroid gland could not be felt. The teeth 
were good. There was a general condition of infiltration of the skin like myxoedema. 
Hebetude was marked. The treatment of this child was with an extract made from 
the thyroid gland of a sheep, 0.06 c.c. (1 minim) of the thyroid extract being given three 
times daily, which was gradually increased 1 minim every two days unless the rectal tem- 
perature rose above 37.7° C. (100° F.). There was a slight improvement of the symp- 
toms before the child left the hospital, but her parents did not return with her to report 
the subsequent progress of the disease. 




Myxoedema. Female, 5% years old. 



Fig. 188 represents a case of sporadic cretinism which occurred in the 
practice of Northrup, of New York, who describes it as follows : 



904 



PEDIATRICS. 



Fig. 188 



' ' The parents of the child were healthy Americans from Western Pennsylvania, 
and they were not consanguineous. The father was forty-five years old ; the mother was 
thirty-nine years of age, had had several miscarriages and four healthy children, two of 
whom had died of some acute disease. This little girl, who is now nine years old, is the 

fifth child. The mother first noticed that 
the child could not sit up when it was 
nine months old, that it practically ceased 
to grow, and now at nine years it is men- 
tally no older than it was at nine months, 
and physically it has merely thickened. 
The first impression one gets on look- 
ing at the child is that it is an idiot. 
Its hands are large and broad. Its color 
is peculiarly sallow. The hair is thin, 
long, dry, and without lustre. The eye- 
brows are present, and are not remark- 
able in any way. She has the character- 
istic flattening of the bridge of the nose, 
diffuse swelling of the under lid and 
puffmess of the upper lid, and pendulous 
cheeks. She has thick, pale lips, with a 
protruding tongue, which is swollen and 
pale. The lips and tongue have a ten- 
dency to dryness. There are fourteen 
teeth ; all of them are of the first set. 
Those in the upper row are eroded, and 
appear only at the bottom of a series of 
ulcers in the upper gums. The lower 
teeth are in nearly the same condition, 
and the gams are suppurating. An of- 
fensive odor is always present in the 
mouth. The arms, legs, feet, and hands 
are unnaturally thick. The abdomen is 
prominent, and there is, as you see, an 
umbilical hernia. The hand which is resting on its mother's black glove shows the 
dry, wrinkled condition so characteristic of myxoedema. Perspiration is absent. The 
skin is pale, and has a peculiar mottled appearance. The soles of the feet and the 
palms of the hands are dry. There is marked lordosis. The surface of the child 
does not suggest the feeling of oedema, nor does it pit. The feeling is that of puffmess 
and flabbiness. The child cannot sit alone. It can, however, stand when once bal- 
anced and allowed to grasp some fixed object. The supraclavicular ' pad' of tissue so 
commonly found in these cases is present. The thyroid gland seems to be present, and 
is possibly enlarged. Hebetude is shown to a marked degree, and the delayed cerebration 
is very evident, although the child never speaks except to say, with infinite slowness, 
' da — da. ' 

"The rectal temperature four days before treatment was begun was 36.4° C. 
(97.5° F.) in the morning, and 37.5° C. (99.5° F.) in the evening. The child was 
treated with the thyroid extract prepared so that each drachm represented one thyroid 
gland of a yearling. Of this preparation 0.06 c.c. (1 minim) was given three times a 
day until the fourth day, when the temperature rose above 37.7° C. (100° F.), and the 
treatment was stopped for a day. At this time the appetite had improved, and the 
breath was not so offensive. Two days later the treatment was begun again, and on the 
eighth day the tongue was found to be considerably smaller. During the next week the 




Myxoedema. Female, 9 years old. Slight improve- 
ment after eighty days' treatment with thyroid 
extract. 



THE DUCTLESS GLANDS IN INFANCY AND CHILDHOOD. 905 

temperature remained under 37.7° C. (100° F.). It then rose above 37.7° C. 
(100° F.), and the treatment was suspended. The first tooth, a canine, was cut at this time. 
The largest dose which was given during the treatment was 0.24 c.c. (4 minims) three 
times a day. The child was treated eighty days in this way. The improvement was very 
slight, but the countenance was brighter, the tongue became much smaller, and the skin 
less dry. She lost somewhat in weight while under treatment. The constipation, which 
was marked when the treatment was begun, disappeared, and she was willing to take a 
much greater variety of food. ' ' 

The next case represents one of sporadic cretinism which came under 
the observation of Osier, of Baltimore, when she was four years old. 

The parents were healthy, and there was no hereditary taint on either side of the 
family, none of whom had had goitre. She was the second child ; the labor was easy, 
and she throve well. She had never had any diseases. Nothing especial was noticed 
about the child until its second year, when it was observed that she did not attempt to 
walk or talk, and that she seemed unnaturally quiet and dull. She did not cut her first 
teeth until she was two years old. In her third year her skin became very pale and 
waxy, and her face and limbs seemed puffy and swollen. She had developed very 
little mentally, and could say only one or two words. The other symptoms indica- 
tive of a disturbance of the function of the thyroid gland gradually appeared, such as 
the myxedematous condition of the subcutaneous tissues and the development of 
the supraclavicular pad. The thyroid gland could not be felt. The examination of the 
blood showed a moderate increase of leucocytes and some irregularity in the size of the 
erythrocytes. When three and a half years old she was 75 cm. (29f inches) tall, and 
her head measured 52.3 cm. (2(H inches). She had been under treatment with tonics 
for a year, and was reported to take more notice and to look more intelligent. She 
was then treated with the thyroid extract, and improved markedly in both her mental 
and her physical condition. The tongue, which had been thick and protruding, 
rapidly became smaller, and she began to walk and talk. 

EXOPHTHALMIC GOITRE. 

Exophthalmic goitre occasionally, but rarely, occurs in childhood, in- 
dependent of the physiological disturbance which has been described 
under hyperemia of the thyroid gland on page 900. 

Etiology. — According to Sachs, heredity plays a much more important 
part in children in the production of the disease than the emotional ex- 
citement, fright, cardiac disease, and severe constitutional disorders which 
so frequently underlie the condition in adults. Epilepsy, chorea, and 
chronic alcoholism in the parents predispose to the development of the 
disease in children. 

Exophthalmic goitre is considered by some writers to be due to a 
pure neurosis, by others to central lesions in the medulla oblongata. The 
more recent views attribute it to hypersecretion of the thyroid gland, to 
which the name hyperthyrea is given, as opposed to the athyrea of myxe- 
dema, in which the symptoms are supposed to be due to deficient secre- 
tion. 

Symptoms. — In some cases the onset is acute, in others subacute or 
chronic, and is characterized by the cardinal symptoms of tachycardia, 
exophthalmos, muscular tremors, enlargement of the thyroid, and by 



906 PEDIATRICS. 

general symptoms of anaemia, indigestion with a special tendency to pro- 
fuse diarrhoea, slight fever, loss of weight, and many other symptoms of a 
neurasthenic character. 

Tachycardia. — The pulse-rate is increased to 90, 100, 120, or even 
200 per minute, the rate being increased in states of excitement and low- 
ered when mental and physical rest is enforced. There is no evidence of 
an organic lesion in the heart. All the arteries throughout the body 
pulsate with unusual distinctness. Owing to the increased blood-tension, 
hemorrhages may occur from the nose, stomach, or intestines. Upon 
palpation of the goitre a distinct thrill may be felt. 

Exophthalmos. — The protrusion of the eyeball is not accompanied by 
disturbance in vision. Limitation of the field of vision with ulceration 
of the cornea from want of protection of the lids may occur. Graefe's 
symptom, a failure of the upper lid to follow promptly a downward move- 
ment of the bulb, Stellwag's symptoms of a dilated palpebral fissure, and 
Moebius's symptom of defective convergence of the axes of the two eyes 
are signs to be noted in connection with the exophthalmos, but are not 
always present. 

Thyroid Enlargement. — The thyroid is almost always enlarged, but the 
increased size may follow rather than precede the other cardinal symp- 
toms. The enlargement is usually bilateral and symmetrical, the tissues 
are vascular, hyperplastic, and may show fibrinous degeneration. 

Muscular Tremors. — The muscular tremors are usually rhythmical, and 
at the rate of about eight to the second. 

Throbbing of the blood-vessels and free perspiration are unpleasant 
symptoms, adding to the discomfort and nervousness of the patient. In- 
tense pigmentation of the skin, resembling Addison's disease, may rarely 
occur, or areas of leucoderma, or of urticaria. Very rarely myxoedema has 
developed towards the end of the disease. Marked diminution in the 
electrical resistance is present, and may be due to the profuse sweating. 
Glycosuria and albuminuria are occasional complications. 

Diagnosis. — The diagnosis is made by the recognition of the cardinal 
symptoms. Physiological hyperaemia of the thyroid at puberty should 
not be diagnosticated as exophthalmic goitre. 

Prognosis. — The course is generally chronic and of several years' 
duration. Some cases recover, but if the disease is once well developed it 
is apt to be prolonged, death often ensuing from some intercurrent affection. 

Treatment. — Absolute rest in bed, avoidance of all excitement, and 
careful regulation of the diet are essential. Digitalis and strophanthus are 
sometimes useful. Good results have been reported from the use of 
belladonna and of atropine. The galvanic current is also recommended. 
The thyroid extract has proved of no value in these cases. When the 
gland is so large as to cause symptoms of pressure, partial extirpation is 
to be considered. The operation has been done in adults with good 
results in a certain number of cases. 



THE DUCTLESS GLANDS IN INFANCY AND CHILDHOOD. 907 

ACUTE THYROIDITIS. 

Acute inflammation of the thyroid is not very common, but may 
'occur from a variety of causes. It may result in the formation of 
abscesses of various sizes or in the production of new connective tissue. 
Acute thyroiditis is rarely primary, being commonly a metastatic affection 
occurring in the course of some febrile disorder. It has been noticed 
among children as a complication of measles, typhoid fever, diphtheria, 
and parotitis, and the process in a majority of these recorded cases, in- 
stead of retrograding spontaneously as it did in others, caused an inflam- 
matory condition in which abscess-formation occurred. On opening the 
abscesses the pus was found to contain numerous micrococci. 

Symptoms. — The symptoms of acute thyroiditis are swelling, redness, 
and tenderness of the gland. Symptoms of pressure, such as dyspnoea, 
hoarseness, painful deglutition, and neuralgic pains, are sometimes present 
with fever and general malaise. The duration of the disease is from two 
to three weeks. 

Treatment. — The treatment is essentially expectant, but some previ- 
ously intractable cases seem to have been benefited by the application of 
iodine. The patient should be carefully watched, and, if there are indi- 
cations that suppuration has taken place, an incision should be made at 
once, as recovery then usually occurs quite quickly. 

TUMORS OF THE THYROID GLAND. 
Malignant growths are extremely rare in the thyroid. Gummata have 
been found in a certain number of cases of congenital syphilis and miliary 
tubercles in connection with general miliary tuberculosis. 

DISEASES OF THE THYMUS GLAND. 

The thymus gland may persist after the sixteenth, and even after the 
twentieth year, without especial pathological significance. 

A considerable number of cases of what is termed thymic asthma has 
been reported. 

In this condition infants and young children, many of whom were 
supposed to be healthy, have had severe and often rapidly fatal attacks 
of dyspnoea, which at the autopsy have been found to be dependent upon 
great enlargement of the thymus gland. Death in these cases is supposed 
to have been due to pressure of the gland upon the trachea, upon the 
great vessels, or upon the pneumogastric nerve, causing spasm of the 
glottis. Many of these cases have occurred in children with rhachitis. 

Minute multiple hemorrhages are not infrequently found in the thymus 
gland in new-born infants who have died of asphyxia. 

Primary inflammation of the thymus gland has been reported, but is 
extremely rare. 

Multiple abscesses of the thymus gland have been reported by Dubois 



908 PEDIATRICS. 

in a number of cases of congenital syphilis. Chiari believes that these 
supposed abscesses were necrotic areas or cysts. Gummata are rare. 

Tuberculosis is rare, but when it occurs it is usually either one of the 
lesions of a general miliary tuberculosis or it is secondary to a tubercular 
pneumonia. The gland may be enlarged, but rarely, in leukaemia, sarcoma, 
cancer, and myo-lipoma. 

According to Reich, the absolute dulness of the thymus, as determined 
by light percussion, is irregularly triangular in outline, the base being 
made by the line connecting the two sterno-clavicular articulations, the 
blunt apex situated at the level of the second rib or slightly below it, and 
the sides a little beyond the edges of the sternum. The larger half of 
this triangle of dulness usually falls to the left side. When the limits of 
dulness, as given above, vary by one or more centimetres, or obscure 
the pulmonary resonance between the upper line of cardiac dulness and 
the lower lateral limits of thymus dulness, an enlargement of the thymus 
is probable. The thymus dulness is present until the end of the fifth 
year, after which it is inconstant. 

Diagnosis. — The diagnosis of diseases of the thymus gland is very diffi- 
cult and generally impossible. Symptoms of dyspnoea and pressure upon 
the pneumogastric nerve, without any other appreciable cause, associated 
with an enlargement of the area of thymus dulness as just described, 
render the diagnosis of some affection of the thymus probable. Reich 
states that swollen lymph-nodes in the anterior mediastinum do not cause 
dulness, but that cheesy lymph-nodes do. 

Treatment. — There is no treatment other than the control of symp- 
toms by appropriate means. 

DISEASES OF THE ADRENAL GLANDS. 
Hemorrhages into the adrenal glands are not uncommon, and are espe- 
cially likely to occur in the new-born. Cancer has been found in rare 
cases. Neither of these conditions is of clinical importance. 

ADDISON'S DISEASE. 

Etiology. — Addison's disease is even more rare in children than in 
adults, only about twenty cases having been reported. The cause of the 
disease is still an open question. The same symptoms occur when differ- 
ent pathological conditions are present. The adrenal glands are supposed 
to furnish an internal secretion which is necessary for normal metabo- 
lism, and a loss of this secretion is considered by some writers to give 
rise to the symptoms, while others believe that the disease is dependent 
upon changes in the ganglia of the sympathetic nervous system of the 
abdomen. 

Pathology and Symptoms. — The onset is usually insidious. Progressive 
loss in strength, with symptoms of secondary anaemia entirely out of pro- 



THE DUCTLESS GLANDS IN INFANCY AND CHILDHOOD. 909 

portion to the degree of anaemia present, and a characteristic discoloration 
of the skin are the conspicuous symptoms of the disease. 

The pigmentation varies from a light yellow to a deep bronze. It is 
usually diffuse, and is most intense on the exposed parts of the body, such 
as the head and hands, and in the flexures, around the nipples and about 
the genitals. The mucous membranes of the mouth and vagina are like- 
wise pigmented, but the palms and soles remain free for a long time. 
Small areas of leucoderma may appear. 

Vomiting and diarrhoea are especially common when the disease occurs 
in children. Nervous symptoms are sometimes marked, and are of the 
same character as those we see in cases of severe secondary anaemia. 
The blood, however, shows only a slight degree of anaemia. There is no 
emaciation except in the later stages. 

The course of the disease is progressive, with occasional remissions, 
the duration varying from a few months to one or two years. Death 
occurs from exhaustion or from the development of an intercurrent affec- 
tion, which may appear as some form of tubercular disease in other parts 
of the body. 

On autopsy the adrenal glands are frequently found to be tubercu- 
lar, but may present no changes. 

Diagnosis. — In the diagnosis of Addison's disease other causes of pig- 
mentation of the skin must be excluded, such as may arise from arsenic, 
lead, nitrate of silver, paludism, and abdominal growths. The tuberculin 
test is often of value as an aid in the diagnosis when the cause is due to 
tuberculosis of the adrenal glands. 

Prognosis. — The disease is nearly always fatal. A few recoveries 
have been reported. 

Treatment. — The adrenal glands of the sheep have of late been used 
frequently in the treatment, and in a few cases with improvement in the 
symptoms. The remedy is worthy of a trial, but the results are usually 
very disappointing. The glands may be given raw or slightly cooked, in 
the form of a glycerin extract, or as a dry extract in tablets. From one- 
half to one gland may be given daily, or one-grain doses of the dried 
extract three times a day. General treatment and measures directed to 
the control of the symptoms are indicated. 



DIVISION XVI. 

DISEASES OF THE NERVOUS SYSTEM. 



We are much more likely to meet with nervous phenomena of the 
most diverse varieties in children than in adults. In like manner we 
meet with the most widely differing clinical symptoms. Symptoms which 
if occurring in adults Avould be significant of serious lesions of the ner- 
vous system may arise in children from simple reflex conditions which 
only simulate and do not represent actual disease. 

Children are much more apt to become unconscious, to have convulsive 
attacks, and to show disturbance of the functions of important nervous 
centres from reflex irritation, than are adults. The whole cerebro-spinal 
system in infancy and early childhood is so impressionable, so excitable, 
and so hypersensitive to even slight grades of irritation, that symptoms 
of a nervous type, whether primary or secondary, dominate all others. 

Reflex phenomena are so much more numerous than those which 
arise from organic lesions, and are so irregular in their manifestations, 
that, from a diagnostic point of view, they are most important. They 
also enter into all disturbances of the nervous system, whether functional 
or organic, to such a degree that what we have learned concerning cere- 
bral localization in the adult becomes of much less value in the young 
subject. 

The reader is referred to especial works on the nervous diseases of 
children for the details of examination and cerebral localization, and I can 
recommend particularly the "Nervous Diseases of Children," by Sachs. 

Instability and irritability of the nervous system, both peripheral and 
central, are characteristic of the early periods of development, making 
certain nervous diseases of children peculiar to them as compared with 
adults. Many w^eeks are required before the peripheral nerves have ac- 
quired their complete function, and the brain and spinal cord do not 
attain their full development for months and years. A simple heightened 
temperature or increase of vascular pressure in the brain and cord may 
cause such irritation of the nervous centres that the most varied symp- 
toms, such as delirium, somnolence, and twitching, may arise. On the 
other hand, serious nervous disturbances may in childhood follow the 
acute infectious diseases, and again there may be a complete arrest of 

910 



DISEASES OF THE NERVOUS SYSTEM. 911 

development of the central nervous system, which may be temporary or 
permanent. 

As stated by Sachs, childhood is exempt only from the diseases due 
to senile deterioration from degeneration and sclerosis of the brain and 
spinal cord, and is relatively free from those due to toxic agents, such as 
alcohol, metallic poisons, and acquired syphilis ; the effects, however, of 
such diseases in the parents are shown by inheritance in the children. 

CONVULSIONS. -ECLAMPSIA INFANTUM. 

Attacks of motor disturbance represented by continuous rigidity or 
contractions of one or more groups of muscles, lasting for a variable 
time and usually accompanied by unconsciousness, are designated con- 
vulsions. A convulsion is a symptom and not a disease. 

Convulsions may be divided, as to their type, into (1) clonic and (2) 
tonic; as to their form, into (1) general and (2) partial; and as to the 
seat of irritation which causes them, into (1) central and (2) peripheral. 

The clonic convulsion is an active spasmodic contraction of the mus- 
cles followed by immediate relaxation. The convulsions of epilepsy are 
illustrative of this type. 

The tonic convulsion is a more or less continued spasmodic rigidity of 
the muscles. This type is seen in tetanus neonatorum. 

The seat of irritation which produces the convulsion is very varied. 
It may be a lesion of the central nervous system or of the peripheral 
nerves ; in the former case the convulsions are spoken of as central in 
the latter they are termed reflex. Convulsions are much more apt to 
occur in infancy than in later childhood and in adult life, probably be- 
cause the power of inhibition is not developed in the former. We there- 
fore not only meet with convulsive attacks more frequently in very early 
life, but, as a rule, we are led to look upon these convulsive attacks as of 
much less import than in the older subject. The reason for this is that 
the causes of reflex convulsions in infancy are innumerable, and. as a 
rule, do not result seriously, while in older children and in adults con- 
vulsions are almost always representative of some serious central lesion. 
Convulsions are so common in infancy that they have been compared to 
the chill which occurs in tha initial stage of many diseases arising in 
adults. The various acute diseases accompanied by high temperature, 
such as pneumonia and the exanthemata, are very commonly preceded 
by a convulsion, and a chill is rare under these conditions in infancy. 
We must, however, not be misled by the frequency and comparatively 
benign character of convulsions in infancy and by the rule that they are 
not fatal. The convulsions of infancy may represent just as serious con- 
ditions as they do in later life, and are to be looked upon as a grave 
symptom until we can be sure, by eliminating serious organic lesions as 
a cause, that Ave are dealing with one of the common and mild forms of 
this phenomenon. The convulsion does not in itself show us whether 



912 PEDIATRICS. 

it is the result of serious or of benign disease, and the convulsions which 
occur from some organic lesion, such as cerebro-spinal meningitis, may 
differ in no way from those which arise from some simple cause, such as 
indigestible food. 

General Symptoms. — We are frequently called to see infants in convul- 
sions where the convulsion is the first and only manifestation of the dis- 
ease. After a few signs of uneasiness the infant suddenly becomes rigid 
for a second or two, makes a sound as though choking, the eyes turn up- 
ward and become fixed, there may be strabismus, the skin becomes some- 
what cyanotic, and then the convulsive movements begin. The eyelids 
open and shut ; the face and usually the head are drawn to one side ; the 
fingers are clinched, and the arms and legs move up and down. The 
back may at times be somewhat arched and the head retracted. The 
infant is apt to foam at the mouth to a greater or less extent ; it is perfectly 
unconscious, and the breathing soon becomes stertorous. These symp- 
toms, after lasting for two or three minutes, are followed by complete re- 
laxation, an apparent state of coma, and sleep. The child on awakening 
may be bright and well, or the convulsion may recur and continue for a 
much longer time, as in one of my cases, in which an infant had fifty-two 
convulsions in twenty-four hours and yet recovered. There may be in- 
voluntary discharges of urine and faeces. 

The convulsive movements may affect the entire body and limbs, 
including the face, or they may affect only certain groups of muscles. 
Thus, they may be localized, as in one limb, or they may be unilateral 
or bilateral. 

Convulsions of Central Origin — The most important, on account of 
their serious nature, are those convulsions which are of central origin. 
Convulsions of this nature may occur in any disease which is represented 
by a high temperature, such as insolation, meningitis, the exanthemata, 
pneumonia, or other diseases. In these cases the convulsions are pro- 
duced either by the action of the high temperature on the motor centres 
of the brain, or by the direct action of the special toxic agent which is 
producing the disease. These convulsions, as a rule, are general, and are 
produced by the diffuse action of the poison. In this class of cases it is 
probable that there is an extremely hypergemic condition of the blood- 
vessels of the central nervous system. The convulsions may also, in 
contradistinction to the supposed theory of active hyperaemia of the blood- 
vessels and the high temperature, be produced by vascular stasis and a 
normal or subnormal temperature. This form may occur in the course 
of pertussis or of cardiac disease. Again, central convulsions are sup- 
posed to be caused by an anaemic condition of the blood-vessels of the 
brain, such as may arise from loss of blood or from exhausting diarrhoea. 
Such toxic agents as are represented by drugs of various kinds, as bella- 
donna, may produce general clonic convulsions. Mental disturbance, 
such as sudden fright, has also been known to produce a convulsive 



DISEASES OF THE NERVOUS SYSTEM. 913 

attack. In all these classes of cases the convulsions may be partial and 
clonic instead of general, although, as a rule, they are general, owing to 
the diffuse character of the irritation. In addition to these convulsions 
which arise from a diffuse cause are others in which a local lesion having 
occurred in the brain from morbid growths, embolism, thrombosis, hem- 
orrhage, or any other cause, a disorganization of a portion of the brain 
has resulted. As these lesions are generally focal in their distribution, 
the convulsions are apt to be localized and hemiplegic in character as in 
cerebral paralysis. 

A number of diseases can by their direct effects, irrespective of the 
temperature which accompanies them, produce convulsions. Thus, con- 
vulsions occur not uncommonly in the course of nephritis, in which they 
are usually called uraemic, also in malaria and in other diseases. Direct 
pressure from tumors of the brain or from hydrocephalus may in like 
manner cause convulsions of either a localized or a general form. Finally, 
we may have these nervous explosions in epilepsy. 

It will be well to remember that this entire class of central convulsions 
emanates from the brain ; and also that when the convulsions are unilat- 
eral or localized we should suspect a central rather than a peripheral 
origin. 

Convulsions of Peripheral or Reflex Origin. — The other class of 
convulsions spoken of as of peripheral origin, and which are called reflex, 
have so many causes that it would scarcely be advisable to attempt to 
enumerate them all. Convulsions of this class may arise from almost 
any source in infants whose nervous system is so easily irritated that the 
slightest cause may produce a nervous explosion. The disease which 
most commonly gives rise to convulsions of the reflex form is rhachitis. 
Rhachitic children seem to be predisposed to spasmodic attacks of all 
kinds, and a general clonic convulsion in children with rhachitis corre- 
sponds to the spasmodic contractions in the larynx which occur in rha- 
chitis, and which is spoken of as laryngospasmus. 

It is probable that there is no special lesion, in connection with the 
rhachitis, which necessarily gives rise to convulsions, but that all the tissues 
in this disease are especially sensitive to causes which may produce reflex 
explosions. 

The most common cause of reflex convulsions in infants is improper 
food. Convulsions from this cause arise not only Avhen manifestly indi- 
gestible articles are given to young children, but even in infants who are 
being fed from the breast. In the early days and Aveeks of life, before the 
breast has acquired its normal functions connected with the elaboration of 
milk in which the solids are in proper proportion to each other and to the 
water, it is not uncommon for the infant to have convulsions produced 
by a disturbance of the mammary function. In cases of this kind it is 
usually found that the percentage of the proteicls is high, and that the con- 
vulsions will continue until this high percentage has been lessened, if the 

58 



914 PEDIATRICS. 

infant is allowed to continue to nurse. Whether the teeth of themselves 
during their development are a source of sufficient irritation to produce 
convulsions has been questioned by many observers. It is, however, evi- 
dent that during the different periods of dentition reflex convulsions are 
more apt to occur than when a tooth is not disturbing the infant's nervous 
system. In addition to the convulsions arising from improper food in the 
stomach during the dental period, foreign bodies in the intestine, whether 
in the shape of food or in that of intestinal parasites, may cause reflex 
convulsions. Foreign bodies in the nose and in the ear have been known 
to produce convulsions, as has also an inflamed tonsil in the initial stage 
of a follicular tonsillitis. Hot baths are so often given to infants when 
they are in convulsions that they should be spoken of as a source of con- 
vulsions, for they have been known to produce this result Avhen care has 
not been taken to test the temperature of the bath before the infant is put 
into it. Mental disturbances, such as arise from fright and other causes, 
are also etiological factors in reflex convulsions. 

Prognosis in Convulsions. — The prognosis in infantile convulsions 
varies with the especial cause. On recovering from the attack the infant 
may show signs of some serious central lesion, such as paralysis, or may 
be left apparently perfectly well. A single convulsion followed by per- 
fect recovery is of slight consequence, bat when the convulsive attacks 
recur frequently and last longer than in the attacks which have just 
been mentioned, the prognosis becomes more grave. Even though no 
central lesion be present, continued convulsions may, by the shock to 
the infant's vitality, finally cause death from exhaustion ; or death may 
occur from spasm of the glottis. Numerous convulsions, however, do 
not necessarily lead to a fatal issue. We must, therefore, irrespective of 
the cause or the apparent result of a convulsion, always look upon it as 
a grave symptom and endeavor to prevent its recurrence. 

Treatment. — When summoned to treat an infant who is in con- 
vulsions, we should first see that the bath, in which we usually find 
that it has been immersed, is not too hot, and should order the infant to 
be taken out of the bath before it becomes conscious, or it may be so 
frightened as to excite again the reflex spasm. The thorax should be 
quickly examined for pulmonary and cardiac lesions, and inquiries should 
be made as to the history of the case, with special reference to the infant's 
diet. The temperature should be taken, and the fontanelle be examined 
for bulging or depression. 

Having obtained this information, we can eliminate a number of causes 
for the attack, such as the onset of one of the exanthemata if the tempera- 
ture is normal, and reflex convulsions from food or from foreign bodies 
in the nose or the ear. If the convulsions arise from exhaustion, stimu- 
lants should be given at once, and if the convulsions continue, the gen- 
eral treatment which is indicated for all forms of convulsions is indicated. 
The treatment should be directed to the especial cause of the convulsion, 



DISEASES OF THE NERVOUS SYSTEM. 915 

if any can be determined. As, however, it is often impossible when the 
convulsion is present to determine whether it is of central or of periph- 
eral origin, it becomes necessary to endeavor to control the attack at once 
by general treatment. For this purpose the inhalation of ether in small 
amounts, and the emptying of the bowels by means of enemata, are in- 
dicated. When the convulsions are of a very severe type, continuing 
with perhaps intermissions of only a few minutes, and the infant's life is 
evidently in danger from the continuous shocks which are taking place to its 
nervous system, a rectal injection of from 0.30 to 1.0 gramme (5 to 15 
grains) of bromide of potassium and from 0.06 to 0.18 gramme (1 to 3 
grains) of hydrate of chloral in 30 c.c. (1 ounce) of warm water, repeated 
if necessary every hour for three or four doses, is indicated. If the con- 
vulsions still continue and a fatal issue is anticipated, a subcutaneous 
injection of sulphate of morphine, beginning with 0.001 gramme (-gV grain), 
should be tried. 

In most cases of infantile convulsions, of whatever form, the warm 
bath at a temperature of not over 37.7° C. (100° F.) can be used, for, 
although it is not in any sense curative, it tends to quiet the nervous ex- 
citability and to lessen the muscular strain produced by the continuous 
spasmodic muscular contractions. The class of cases in which this is 
contraindicated are those which are caused by a loss of blood, an anaemic 
condition, diarrhoea, and cardiac disease, and those in which venous stasis 
is present with a lowered temperature. In these cases stimulants are in- 
dicated. 

When there are symptoms of the diseases which I have already spoken 
of which are accompanied by high temperature, the reduction of the tem- 
perature by the bath and the administration of an antipyretic are indi- 
cated. 

The treatment of convulsions caused by definite diseases is simply 
symptomatic while the convulsions continue, and later appropriate treat- 
ment of the primary condition. 

The following cases represent eclamptic attacks from various causes : 

A little girl, six and one-half years old, was healthy at birth, and had never had 
any disease. When three and one-half years old she had from time to time convulsions, 
clonic in type. When in the convulsions she did not bite her tongue. The first con- 
vulsion occurred when she was three years old ; the next when she was four years old ; 
the next when she was four and one-half years old ; and the last one when she was 
five years old. 

As all these convulsions were apparently produced by the same cause, it will only 
be necessary to describe them in a general way. They were characterized by sometimes 
continuing much longer than is usual in infantile convulsions, one of them having 
lasted for one hour and a half, during which time the hands were clinched, the eyes 
were rolled up, and the entire body and limbs were convulsed. Previous to each 
attack the child for a number of days had indefinite symptoms, which she could not 
describe accurately, connected with the abdomen and accompanied by a feeling of 
weakness and slight muscular twitching. 



916 PEDIATRICS, 

At the time of the earlier attacks her mother found that these symptoms could be 
dissipated and a convulsion apparently prevented by giving her a dose of castor oil about 
once a week. After the third convulsion she passed a lumbricoid worm. From that 
time whenever she showed the premonitory symptoms of a convulsion she was treated 
with santonin followed by a cathartic, a lumbricoid worm each time was passed, and 
the symptoms disappeared. When she was five years old she was thoroughly treated 
for these lumbricoid worms with santonin, and after a large, ascaris had been passed 
the nervous symptoms ceased entirely. The child when last seen had not had a con- 
vulsion for over a year. There had been no reappearance of the parasites. 

This child represents the class of cases described as reflex convulsions, the cause 
Of the peripheral irritation being an intestinal parasite. 

Another case was that of an infant, four months old. Her mother, who was strong 
and well and apparently had plenty of good breast-milk, nursed her at birth. When 
she was three months old she began to have convulsions, which occurred almost every 
hour. Suspecting that the proportion of solids in the breast-milk was too high for the 
infant to digest, and that it was producing a peripheral irritation which was the cause 
of the reflex convulsions, I had an analysis of the milk made, and found that the pro- 
teids showed a percentage of from 4 to 5. The infant was then fed with a carefully 
modified milk in which the percentage of the proteids was made 1. Within a few hours 
the convulsions ceased, and they have never returned. 

A case similar to the one just described was that of a boy three weeks old, previ- 
ously healthy and strong, and digesting his mother's milk perfectly ; he was weaned 
and given by mistake a mixture containing a total proteid of 3.50. He then began to 
have convulsions, which continued until a new mixture was giv^n, in which the total 
proteid was 1.50, when they ceased. 

CHOREA. - SYDENHAM 1 S CHOREA. 

Chorea is a disease characterized by irregular and involuntary mus- 
cular movements without loss of consciousness, and affecting the muscles 
of volition. 

The disease is rare in infancy, but may occur in the early months of 
life. It seldom begins after puberty. It is most apt to begin and is most 
marked in its symptoms during the period of the second dentition, — that 
is, during the period of active growth, from six years to puberty. The 
greatest number of cases is found among the female sex and among those 
who do not receive sufficiently nutritious food. A sharp distinction 
should be made between the disease chorea, with its characteristic chorei- 
form symptoms, and the same choreiform symptoms resulting from other 
diseases, sometimes represented by central nervous lesions, sometimes by 
purely reflex causes. It will save much useless reading of the literature 
of chorea and much profitless discussion as to its etiology and pathology 
if this distinction is borne in mind. Eliminating those forms of chorea 
which are due to gross lesions of the nervous system, such as the 
post-hemiplegic and congenital forms, we can at once very materially 
reduce the cases of true chorea. In like manner we should separate 
from true chorea those cases of peripheral irritation in which the partial 
choreiform symptoms are evidently reflex and can be cured by removal 
of the cause. Examples of these reflex choreiform symptoms are the 
facial chorea from naso-pharyngeal irritation and the partial choreiform 



DISEASES OF THE NERVOUS SYSTEM. 917 

movements occasionally arising from errors of refraction and ocular in- 
sufficiency. The consideration of these anomalous forms of chorea 
belongs with the diseases in which they occur. 

Etiology. — Chorea can be brought about by other diseases, such as 
measles, although this, in my experience, rarely occurs, and even then 
chiefly among the poorly cared-for. A certain number of cases have so 
directly followed intense fright that we must acknowledge acute mental 
conditions as a cause. The disease which is most frequently associated 
with chorea is rheumatism. The percentage of cases, however, in which 
this association takes place is difficult to determine. This difficulty arises 
from the want of uniformity in the reported cases of different observers, 
due to their different ideas as to what constitutes rheumatism. If only 
the cases of acute articular rheumatism are to be classified under rheuma- 
tism, very few cases of associated chorea need be spoken of; while if all 
the flitting aches and pains of childhood are considered to be rheumatism, 
the number of choreic cases caused by rheumatism rises to fifty per 
cent., or possibly more. The truth will in the future probably be found 
to lie in some intermediate number, for in certain cases a close connection 
exists between chorea and rheumatism. The difficulty becomes still 
greater when we examine the relationship between chorea and endocar- 
ditis. When there is a rheumatic element in the case we should expect 
a cardiac lesion to arise which may be dependent on the rheumatism. 
In certain cases, however, Ave find chorea with endocarditis entirely irre- 
spective of rheumatism. This occurs to such an extent that in chorea 
we should watch for cardiac lesions just as carefully as in acute articular 
rheumatism. Heart-murmurs of a ha?mic nature may occur in chorea 
as in any other disease of a debilitating nature. They should, however, 
always be looked upon seriously, as possibly indicating an insidious 
form of organic endocarditis, which, instead of being evanescent and 
passing off entirely Avith the recovery of the chorea, may either seriously 
disable the heart or lead to a fatal issue. A special microbic cause for 
chorea, as for rheumatism, must be thought of, but as yet has not been 
proved to exist. An hereditary tendency to nervous explosions of a 
choreic type has long held a prominent place in the etiology of chorea. 
This tendency does not manifest itself, hoAvever, unless the children are 
poorly nourished, badly cared for, or exposed to nervous excitement 
during their school life. 

Overtaxing of the central nervous system during the school year has 
so often been shoAvn to result in an attack of chorea in the spring and in 
a recurrence in the autumn on returning to school, that it should be 
recognized in considering the etiology of the disease. Strain of the ocular 
muscles has been considered an exciting cause of chorea, but beyond 
causing in some cases choreiform symptoms it cannot be considered as 
being an inciting cause of true chorea. 

Pathology. — There are a large number of cases of chorea in Avhich 



918 PEDIATRICS. 

the disease is found to have no apparent pathological lesion. Its symp- 
toms, however, show us that the morbid process is located in some part 
of the central nervous system. Whatever the nature of the lesion, it is 
represented by a profound excitement of the motor centres, presumably 
due to their inanition, and is accompanied by a temporary inability of 
these centres to recover themselves. Many lesions have been described 
as occurring in chorea, but in the pure cases (Sydenham's chorea) which 
have just been described, and which really represent the disease, there is 
no lesion which with our present knowledge we can say is characteristic. 

Symptoms. — Chorea may be in its distribution general or partial ; in its 
course acute, subacute, or chronic. In many cases the disease is exceed- 
ingly mild in its symptoms and is of a benign type ; in others it assumes 
a severity which seems to threaten life. The beginning, although at times 
sudden, as from fright, is, as a rule, gradual, at first a few muscles only 
being affected. The child becomes fretful and impatient. Its irritability 
must carefully be differentiated from bad temper, for which the symptoms 
are apt to be mistaken by the family. The clinical picture of the disease 
is a jerky, irregular, involuntary contraction and relaxation of the mus- 
cles, which usually begins in the fingers, hands, and face. There is an 
irregular, uncertain action of the part affected, and efforts of the will 
only partly control the movements. As the disease progresses, the vol- 
untary control of the muscles diminishes more and more, and at times 
disappears entirely. 

The movements ordinarily cease during sleep, but in severe cases 
they continue and even interfere with it. At times the child is unable to 
walk, on account of Aveakness. The speech may become slow and indis- 
tinct, from the affection of the muscles of the tongue and of the larynx, 
and even mastication and deglutition may become difficult. In very 
severe cases the difficulty in speech may be enhanced by the mental con- 
dition, which may be represented by dulness and apathy. The tendon 
reflexes are lessened in severe cases. The muscles grow weak and soft, 
and there is considerable emaciation. There is usually loss of appetite, 
and the bowels are often constipated. The urine and its urea have been 
found to be increased during the course of the disease. The dynamom- 
eter usually shows impaired muscular power. In certain cases the 
muscles of the extremities on one side of the body are principally or 
alone affected (hemichorea). These cases do not differ from the ordinary 
bilateral cases in any way except in this respect. 

In very severe cases there may be involuntary evacuations of the 
faeces and of the urine. The disease is distinct from epilepsy, and there 
is little danger of the patient becoming epileptic unless the disease hap- 
pens to develop in an individual who is predisposed to that condition. 

Prognosis. — Chorea is very apt to show relapses and to recur for 
several years. Although often obstinate in the persistency of its symp- 
toms, yet it may be said to be self-limited, and, as a rule, to recover, pro- 



DISEASES OF THE NERVOUS SYSTEM. 919 

vided no complications, such as of the heart, arise. The time which 
elapses before complete recovery is very variable, but well-marked cases 
usually extend over a period of three or four months. Although chorea 
is considered, as a rule, a benign disease, yet we must always look upon 
it as a serious disturbance until we are sure that we are dealing with the 
usual mild form of the affection. The following case illustrates how care- 
ful we should be to give a guarded prognosis in the early stages of acute 
chorea : 

A girl, nine years old, reported by Cook and Beale, began to have choreic move- 
ments, which constantly became worse. Delirium developed, with a slight fever, a 
rapid and feeble pulse, and a quick and interrupted respiration. Death suddenly oc- 
curred one hundred and thirty hours after the onset of the disease. The autopsy 
revealed extreme anaemia of the pons and medulla, but no other changes of note in 
other parts of the body. 

We must allow that even uncomplicated chorea is a varying disease 
as to the severity of its symptoms and their persistence for a longer or a 
shorter time. We also know that there is a marked tendency to relapse, 
and that the number of relapses varies to a great degree. The length of 
the attack and the response to treatment may differ much. Bearing these 
facts in mind, we can understand the rapidity with which certain indi- 
viduals are attacked or the quickness with which they recover. Some 
cases recover rapidly under only hygienic treatment, while others are 
apparently unaffected by any drug whatever. When heart-murmurs, 
evidently representing organic disease, appear, it is often a cause for com- 
ment at the comparatively slight discomfort which the cardiac lesions 
entail. At times, again, it is surprising how rapidly fatal are some cases 
which are complicated by cardiac disease, and how they are uncontrolled 
by any treatment whatsoever. The disease is variable in its duration 
whether treated by drugs or not. 

Treatment. — There cannot be said to be any specific treatment with 
drugs for chorea, but of the many remedies that have been used, arsenic 
has, in my experience, been the most beneficial. It should, however, be 
used with care, and on the appearance of any evidence of the physiologi- 
cal action of the drug, such as nausea or oedema of the eyelids, at once 
be discontinued. It should not, as a rule, be given in very large doses, 
as cases have occurred in which it has produced a multiple neuritis of 
many months' duration. When any special cause can be found for the 
attack, such as rheumatism, appropriate treatment directed to that cause 
should be employed. It is manifest, however, in the uncomplicated cases 
that our main reliance must be placed on hygiene and food. Fresh air, 
nutritious food, hot baths, tonics to control the anaemia and general pros- 
tration, kindness, seclusion to secure mental quiet, stimulants if there is 
much resulting weakness, and the bromides for insomnia and over-excite- 
ment are the means which I have found most valuable in managing this 



920 PEDIATRICS. 

disease. I have seen well-marked cases get well in from sixty to seventy 
days where good food and a small amount of stimulant constituted the 
entire treatment. 

If the attack is very severe, skilled nursing is a very important ad- 
junct in the treatment. The child should be protected from harming 
itself by means of a padded bed, and light but well-padded splints to 
control the movements during sleep are indicated occasionally. 

The following cases illustrate the different phases of chorea : 

A girl, six years old, represented one of the milder forms of chorea. There was 
no history of nervous or cardiac disease or rheumatism in the family, and the child 
herself had never been sick before. 

She first complained of pain in her left hand and arm, and later the muscles of 
the arm began to twitch. Soon after the whole body was affected in the same way. 
Somewhat later it was found that the child could not talk plainly, and it was with 
some difficulty that she could feed herself. She seemed nervous and peevish, and 
showed constant irregular incoordinate movements, chiefly of the face, mouth, and 
upper extremities. The legs were slightly affected, and sometimes the muscles of the 
trunk. There had been no paralysis of the muscles. The eyes were normal in their 
reaction. 

She was treated chiefly without drugs, and especial attention was paid to giving 
her a nourishing diet, baths, gentle massage, and rest in bed in a quiet room. A 
physical examination showed nothing abnormal in connection with the heart or other 
organs. An examination of the urine showed it to be normal. Marked improvement 
was shown after she had been treated for two weeks, and at about the forty-second day 
from the onset of the disease she had recovered completely. 

Another girl, thirteen years old, represented one of the milder forms of 
recurrent chorea. 

She had a number of diseases preceding her first attack of chorea. When she was 
two years old she had diphtheria, when five years old, measles, when seven years old, 
scarlet fever, and when eight years old, rheumatism. When nine years old she had her 
first attack of chorea, which occurred in the spring of the year, and lasted for a num- 
ber of months. This was followed in the spring of the next year by a second attack. 
In the spring of the following year she had a third attack of the disease ; at this time 
the incoordinate movements were not so marked as in the previous attacks, but the 
debility was greater. When she was examined during this attack, it was found that 
the heart, although weak and somewhat irregular, presented no evidence of murmurs. 
The pulse was 84, the temperature was normal, and there were no signs of any other dis- 
ease. She was treated at the hospital, and recovered in a few months. In the spring 
of the next year she had a fourth attack of chorea. At that time nothing abnormal 
beyond the choreic movements was noticed. She was treated with from 0.18 to 0.36 
gramme (3 to 6 minims) of Fowler's solution three times a day, and in a few months 
left the hospital apparently well. 

In the spring, one year from the beginning of the fourth attack, she entered the 
hospital with a fifth attack. On this occasion, after using Fowler's solution for a few 
weeks and not obtaining any special benefit, iron and nux vomica were given. She 
gradually improved under this treatment. There remained for some time, however, 
incoordinate movements, which appeared especially when she was embarrassed by the 



DISEASES OF THE NERVOUS SYSTEM. 921 

observation of the people who were around her. It was a case in which a good prog- 
nosis could be given, as there were no cardiac or other complications. 

The following case illustrates recurrent chorea with the development 
of a functional disturbance of the heart, resembling organic disease. 

A boy, nine years old, was subject to attacks of chorea for nearly four years. The 
attacks usually came on in the spring with considerable severity, and continued for 
nearly six months, gradually diminishing in intensity until the symptoms were scarcely 
noticeable. The child had a history of rheumatism, not, however, of a high grade. 
The attack began four months previous to entering the hospital, and was quite a severe 
one, so that he had been unable to control the movements of his hands and face during 
the day ; they were, however, quiet at night. 

On entering the hospital a physical examination showed a marked systolic mur- 
mur, heard most distinctly at the apex and transmitted to the axilla. The area of car- 
diac dulness was not especially enlarged. The urine was normal, and nothing else 
abnormal was detected about the child. 

He was at first treated with Fowler's solution, 0.12 gramme (2 minims), three 
times a day. After four days the choreic movements became less marked and the car- 
diac souffle less distinct. Two days later, however, the Fowler's solution had to be 
omitted, as it caused nausea and vomiting. At this time there was a double souffle, 
heard most distinctly over the left third interspace, close to the sternum. A few days 
later Fowler's solution was renewed, but as it caused gastric disturbance, again had to 
be omitted, and it was found that it could not be given for more than two days at 
a time without causing puffiness of the face. The treatment, therefore, consisted chiefly 
of rest in bed, good food, bathing, massage, and the administration of iron in the form 
of the citrate of iron and potassium. 

One month later the choreic movements had decidedly lessened, and the cardiac- 
murmurs disappeared. Two months from the time he entered the hospital he was free 
from all symptoms of the disease. 

The next case illustrates a severe case of chorea, following an attack 
of influenza, and terminating fatally, without the development of any 
complication : 

A boy, ten years old, had always been delicate, but had had no especial disease, 
such as rheumatism, until six weeks previous to the time when I saw him, when he was 
said to have had an attack of epidemic influenza. He recovered completely from the 
disease in ten days. Three or four days later he began to show symptoms of chorea. 
These symptoms gradually increased in severity, and finally were continuous, except 
when he was asleep. After he had had the chorea for one week he was unable to articu- 
late, and began to have trouble with deglutition. He soon lost the control of his limbs, 
grew very weak, and was confined to his bed. There was considerable insomnia. In the 
second week of the attack the choreic movements became so violent as to endanger 
his falling out of bed. The temperature up to the time when I saw him, in the fourth 
week of the attack, was normal. The pulse varied from 140 to 150, and the respira- 
tions from 35 to 40. 

When I saw him, at the end of the fourth week from the beginning of the chorea, 
his mind was perfectly clear ; he had a little pain in the hands and shoulders, appar- 
ently from the continual movements. He was unable to articulate clearly. There 
was difficulty in swallowing, and he was considerably emaciated. Nothing abnormal 
was found in the lungs. The heart was beating tumultuously. The area of cardiac 
dulness was very slightly enlarged, but there were no cardiac murmurs. Although in 



922 PEDIATRICS, 

many of these severe cases of chorea no evidence of cardiac disease can be obtained 
on physical examination beyond a slight dilatation of the left ventricle, yet some dis- 
ease of the endocardium or valves may often be found at the autopsy. In these cases, 
however, the temperature is, as a rule, raised. In this case the continuous normal 
temperature and the absence of any signs of cardiac disease beyond a slight dilatation 
from the apparent weakness of the ventricular muscles seemed to indicate that it was 
a case of simple chorea without disease of any of the organs. 

Although the child was carefully nursed and remedies of various kinds were em- 
ployed to strengthen the action of the heart and to support his general strength, he 
failed rapidly, and died of exhaustion a few days after I saw him. 

In the following case (Fig. 189) we have an example of acute articular 
rheumatism with endocarditis, in the course of which chorea developed 
with other complications, which terminated fatally : 

Fig. 189. 



Rheumatic arthritis. Endocarditis. Cardiac enlargement. Chorea. Female, 8 years old. 

The child was eight years old. She had been subject to attacks of rheumatism. 
She had not had any especial diseases, with the exception of an attack of measles when 
she was three or four years old, until she had an attack of rheumatic arthritis when 
seven and one-half years old. At that time she was confined to bed with fever, and 
with pain, tenderness, and swelling in all her joints, especially of the knees and fingers. 
Although she recovered from the acute symptoms of the rheumatism, she had since 
then never been able to use her arms and hands, nor able to walk much. There was 
no record of the condition of her heart during the attack of rheumatism, but there was 
no history of previous cardiac disease. During the course of the rheumatism there 
were no other especial symptoms noticed, except that her disposition was evidently 
much changed and she became peevish and fretful. 

One week before entering the hospital she began to have choreic movements. They 
were moderate in degree, but incessant. A few days later the incoordination of the 
muscles was also noticed when she endeavored to speak or to swallow. There were 
continual choreic movements of the eyes, face, and fingers, and, although seemingly 
she could understand what was said, she was unable to speak clearly. She was much 
emaciated. Incoordinate movements of all the muscles of the face, eyes, head, neck, 
body, and extremities were present. The peculiar look which occurs in these cases, 
expressive of embarrassment, was clearly shown. Although the case was a severe one, 
the mind was not affected beyond a slight degree of hebetude. On physical examina- 
tion the lungs were found to be normal. On examining the cardiac region the impulse 
of the heart was found to be outside of the mammillary line and in about the sixth 



DISEASES OF THE NERVOUS SYSTEM. 923 

interspace. On palpation the contractions of the heart were clearly felt, but were irreg- 
ular and not so strong as normal, suggesting irritability and incoordination of the car- 
diac muscles. On percussion there was normal resonance to the right of the sternum 
and under its upper part as far as the third right interspace. There was dulness under 
the sternum, beginning at the second left interspace, extending across to the third right 
interspace, and involving the lower part of the sternum. The area of cardiac dulness 
is marked in black in Fig. 189. It extended upward to the left of the sternum as far 
as the second rib, then to the left and downward outside of the mammillary line until 
it reached the impulse of the heart in the sixth left interspace. On auscultation a 
murmur was heard most distinctly with the first sound at the apex of the heart, and 
was transmitted to the axilla and to both sides of the back. This murmur was trans- 
mitted to the base, but gradually lessened as the area of the large vessels at the base 
of the heart was reached. Nothing else abnormal was detected on physical examina- 
tion. 

This was a case in which during the course of a rheumatic attack an endocarditis 
had developed. This endocarditis had been followed by enlargement, mostly repre- 
sented by dilatation of the left ventricle. During the course of the rheumatism and 
of the cardiac complication the chorea had developed. 

The prognosis in a case like this must be very guarded. In some instances the 
disease, or rather combination of diseases, grows rapidly worse, and the child dies 
seemingly from exhaustion. In cases of a milder form the child gradually recovers from 
its chorea and from its rheumatism, but is left with an organic disease of the heart 
from which it never recovers. The cardiac disease, however, can in most cases be 
much benefited by careful treatment, especially by rest in bed. In these cases the dila- 
tation grows decidedly less, while the heart becomes stronger, and, as the chorea 
passes away, may show a normal area of dulness. We may at any time expect in place 
of gradual improvement a decided increase in the severity of the symptoms. The val- 
vular lesion of the heart may become much more extensive, assuming the ulcerative 
form which is usually so fatal. The pericardium may become affected, and broncho- 
pneumonia occur as a complication. 

The treatment in this case was with milk and stimulants. It was impossible for 
her to take solid food, and the milk was with the greatest difficulty introduced into her 
mouth. 

The subsequent history of the case was as follows : The temperature rose to 40° C. 
(104° F.),.and was accompanied by precordial pain and a pericardial friction-rub, but 
no physical signs of effusion. There was dulness under the left clavicle, but at first, 
beyond rather indefinite signs of bronchitis, nothing abnormal was detected in the 
lungs. The liver was somewhat enlarged. The axillary lymph-nodes were enlarged. 
There was great atrophy of the muscles. There was diarrhoea and incontinence of urine. 
The hebetude increased. Areas of dulness and diminished respiratory sound were 
detected. There was dyspnoea and rapid failure in strength. The child died on the 
thirty-seventh day from the beginning of the disease. 

The autopsy showed the following lesions : Chronic pericarditis and mediastinitis ; 
acute ulcerative endocarditis ; thrombosis of the innominate and left jugular veins ; 
broncho-pneumonia ; passive congestion and oedema of the pericardium. 

I have tried various methods of administering milk and stimulants in 
cases like the preceding, but have found that the jaws close so spasmod- 
ically whenever a spoon is introduced between the teeth that the milk is 
usually spilled before it enters the mouth. The method which I have 
found to be most successful is by a feeding-cup with a rubber nipple fitted 
to the neck of the cup. The rubber nipple is perforated with a large hole. 



924 PEDIATRICS. 

The soft rubber does not incite the choreic movements of the jaw to the 
degree that anything hard Avould do. The Breck feeder (page 272) is 
also useful in these cases. 

CHOREIFORM DISEASES. 

Hereditary or Huntington's Chorea. — This form of chorea differs 
from Sydenham's chorea chiefly in its hereditary character and in the 
much greater degree of muscular incoordination. It almost invariably 
appears between the ages of thirty and forty. It need merely be men- 
tioned in connection with children on account of its hereditary character. 

Habit Chorea. — This condition is common in children. It includes 
simple incoordinated movements, usually of the eyes, mouth, shoulder, or 
thighs. They have been called "habit spasms" or "tics.' 1 Imitation is 
probably a strong factor in the etiology. It may follow from true chorea. 
These habit spasms may become chronic and persist throughout life. 
The treatment consists entirely of discipline of the child, and the earlier 
this is begun and the more strictly it is enforced the better it will be for 
the child. 

Chorea Blectrica. — This is a very rare condition occurring in child- 
hood and adult life, and seen chiefly in Italy. It is characterized by 
violent spasmodic movements of the neck and head and sometimes of 
the extremities. In the course of a few months paralysis occurs in the 
affected muscles with marked atrophy and loss of faradic irritability. 

Myotonia Congenita. — Myotonia congenita (Thomsens Disease) is 
characterized by an inhibition of the voluntary movements. This disturb- 
ance of movement is due to a stiffness and tension of the muscles occur- 
ring at the beginning of motion. The most important etiological factor 
in the disease is that it is hereditary. In almost every case it begins 
in early childhood. 

An examination of sections of muscle taken from cases of this dis- 
ease has shown an enormous hypertrophy of all the muscular fibres, 
great proliferation of the nuclei, and a slight increase of the perimysium. 
The disease appears to be a congenital affection of the muscular fibres. 

Symptoms. — The symptoms are noticed only during voluntary move- 
ments, the contraction of the muscles responding very slowly to the will, 
and persisting for a little time after the individual has willed the muscular 
movement to cease. After a period of quiescence, the muscles become stiff 
and respond to the will only with difficulty. A tap upon the muscles 
causes a slow, tonic contraction, which relaxes slowly. Long-continued 
rest, heat, cold, and excitement cause an exaggeration of the symptoms. 
The muscles of the arms and legs are those usually implicated. Sen- 
sation and the reflexes are normal. The muscles are apparently enlarged, 
giving at times the appearance of hypertrophy, but the strength of the 
muscle is not proportionate to its size. Erb has described a charac- 
teristic electrical reaction, called the myotonic reaction, in which the con- 



DISEASES OF THE NERVOUS SYSTEM. 925 

tractions caused by either current attain their maximum slowly and relax 
slowly, and wave-like contractions pass from the cathode to the anode. 

Diagnosis. — The diagnosis is made by the characteristic difficulty in 
making volitional movements, by the peculiar contraction which follows 
a slight tap on the muscles, and by the presence of the myotonic reaction. 

Treatment. — Although at times it may recover temporarily, the disease 
is incurable, and there is no known treatment which is of much benefit, 
although active exercise is indicated and is in most cases desirable. 

Congenital Paramyotonia. — Congenital paramyotonia is a rare con- 
dition sometimes resembling myotonia congenita. It is an hereditary affec- 
tion characterized by tonic spasms lasting from several minutes to several 
hours and coming on soon after birth. There is no myotonic reaction. 

Paramyoclonus Multiplex (myoclonia). — The principal symptom of 
this condition is a clonic spasm of the muscles of the extremities, the face 
generally being exempt. The condition is very rare in childhood. The 
attacks occur at intervals. Symmetrical muscles are affected, and there 
is but slight myotatic irritability. 

EPILEPSY. 

Epilepsy is presumably an organic disease of the nervous system in 
which the pathological lesion has not yet been determined. 

The characteristic symptoms are attacks of unconsciousness with or 
without convulsions, with a great liability to a recurrence of these attacks 
through a long period of time. The transient loss of consciousness with- 
out convulsions which occurs in epilepsy is called petit mal, while the loss 
of consciousness with general convulsive manifestations is called grand 
mal. Convulsions precisely similar to those occurring in true epilepsy 
may occur in organic cerebral disease as the result of external trauma- 
tism or from other causes ; such convulsions have been termed epileptiform. 
The term Jacksonian epilepsy is applied to localized convulsions which are 
the result of organic cerebral affections. These latter forms must not be 
confounded with true epilepsy. 

It is important that a sharp distinction should be made between the 
convulsions of true epilepsy and the many reflex convulsive attacks 
which come from a variety of causes and arise from the hypersensitive 
condition of the infant's nervous system. These reflex convulsions so 
closely resemble the convulsions which occur in epilepsy that the great 
importance of distinguishing between the two diseases can hardly be ex- 
aggerated. In the infant's rapidly growing brain the irritability of certain 
motor centres is physiologically far greater than in later childhood and 
in adult life. This irritability is the source of nervous explosions pro- 
duced by many causes, often slight in their nature, and it is impossible to 
differentiate these explosions by their clinical symptoms alone from the 
convulsive attacks of epilepsy. 

Etiology. — It is usually granted that the initial lesion of true epilepsy 



926 PEDIATRICS. 

lies somewhere in the cortical motor centres of the brain, and that the 
epileptiform convulsion is an irritation of these centres. True epilepsy 
may, of course, originate in early infancy, and does so in a large number 
of cases. Whether, however, infantile convulsions may be the cause of 
epilepsy is a very different question. The fact is that we do not as yet 
know what produces epilepsy. The various etiological factors which are 
usually cited, such as fright, injury, and dentition, probably have nothing 
more to do with the production of the disease than to precipitate its de- 
velopment in an individual who is already predisposed to it. Inheritance 
as a cause of epilepsy will presumably, in the future, hold a much less 
prominent place than has been granted to it in the past. 

There is no good reason for believing that reflex convulsions in them- 
selves ever lead to true epilepsy. It is of considerable importance that 
we should be able to allay the natural alarm of parents by telling them, 
after the convulsions have ceased for a sufficient time to allow us to say 
that they are not epileptic, that there is no chance of their having pro- 
duced an epilepsy which will develop later. 

Symptoms. — Epilepsy may begin in infancy or at any time throughout 
childhood, but a frequent time for its development is at puberty. 

Petit Mai. — The petit mal may exist in different degrees of severity. 
In the mildest form, which may often pass unnoticed unless the attendants 
are especially on the watch for it, the child stops for a moment in its occu- 
pation, whether speaking, eating, or playing, while its eyes become fixed 
and it assumes a vacant expression. This condition may last for only a 
few seconds, when the child assumes its former occupation as though it 
had never been interrupted, and usually is not aware that anything has 
happened. In other cases this condition lasts a little longer, and slight 
twitching of the lower part of the face and of the extremities may occur. 
In other cases, again, the attacks are more severe, the child complains of 
being dizzy, staggers, has slight convulsive movements, and turns pale, 
this condition lasting for a minute or more, and being quite marked, but 
without any total loss of consciousness. Momentary attacks of stagger- 
ing sometimes occur alone in place of the attacks above described. At 
times these attacks of petit mal are the only manifestations of the dis- 
ease, but in severe cases they are apt to be accompanied by occasional 
attacks of grand mal. They may occur as often as twenty or thirty times 
a day, or, on the other hand, they may be noticed only once in four or 
five days, and sometimes they are absent for longer intervals. 

Grand Mal. — In the grand mal the attacks are of much greater 
severity. They are sometimes preceded for several hours by a feeling of 
malaise or general discomfort, but this is not always present. Patients 
sometimes have notice of the sudden onset of the attack, and such notice 
immediately preceding the convulsions and forming part of the attack 
itself is called the aura. This aura may be of different kinds. It is most 
commonly a sense of fulness or oppression in the epigastrium, from which 



DISEASES OF THE NERVOUS SYSTEM. 927 

something seems to rise into the throat, and unconsciousness supervenes. 
It may be, however, a pain or a sensation of numbness, tingling, or other 
form of paresthesia in various parts of the body. Sometimes tinnitus is 
the first symptom. Frequently the patient has no warning whatever of 
the attack, but falls unconscious with or without a cry. The face be- 
comes congested, and the eyes usually turn upward so that only the 
whites can be seen. After this follows the stage of tonic convulsions, 
which is sometimes so short that it is overlooked. Then come the clonic 
convulsions, which in typical cases are general, although the limbs on one 
side of the body are sometimes more affected than those on the other 
side. The movements of the limbs are apt to be very violent, the hands 
are clinched, the thumbs being flexed on the palms and the fingers closed 
over them. In many cases the patients froth at the mouth. In the more 
severe cases the children bite their tongues and pass their urine involun- 
tarily. The duration of such attacks is usually five or ten minutes, but 
one attack may succeed another with little or no intermission. When the 
attacks follow one another in this way for several hours the patient is said 
to be in the epileptic status, and his condition as regards life is very serious. 
After the convulsion ceases the child's breathing becomes stertorous and 
the limbs are relaxed. Later, and before consciousness fully returns, the 
child often falls into a deep sleep, and on waking has no recollection of 
the attack, but complains only of headache and of mental confusion. 
Attacks often occur in the night, and in this way may be overlooked, the 
only evidence of them being that the child has wet the bed. In certain 
cases, when only nocturnal attacks have been present, we often have 
reason to believe that the disease has existed for considerable periods 
before its presence was suspected. In some cases in connection with 
the attacks there is a desire to walk or to run, so that the patient must 
be closely watched. In this condition children may walk straight against 
an obstacle, though they are more apt to stop when something comes 
across their path. Sometimes they walk or run in circles. 

The cases of paroxysmal running described by Bullard are at times 
the early manifestations of an epilepsy which will develop later, although 
they may also be only the symptoms of hysteria, chorea, and organic 
cerebral disease. 

Epileptic children are liable to bursts of ungovernable anger and vio- 
lence lasting for hours, in which they may tear and destroy things, bite 
the mother or nurse, and are apparently for a time under the influence of 
illusions and hallucinations. 

The condition of patients between the attacks is in the lighter cases 
and in the beginning of the disease usually quite normal. As the disease 
progresses, however, there is a tendency to mental impairment, and in the 
more severe cases, in contrast to the lighter ones, we are apt to find some 
enfeeblement of intellect, which at times may go on to an advanced 
dementia. 



928 PEDIATRICS. 

Diagnosis. — As the convulsive attacks occurring in epilepsy cannot be 
distinguished clinically from similar attacks due to other causes, we are 
forced to differentiate epilepsy from other diseases by carefully eliminating 
other causes for the convulsions. We must also wait to see whether the 
attacks will continue indefinitely, in which case they are more likely to be 
epileptic. 

The diagnosis of epilepsy is made from a continuance of the attacks 
after a considerable period without evidence of any organic disease or 
reflex irritation. When the child bites its tongue during the attack and 
goes to sleep after the convulsion, or when there is temporary mental 
impairment after the convulsion, we have good reason to state that the 
convulsions are due to true epilepsy, especially if no symptoms of organic 
brain disease coexist. 

Epileptic are easily distinguished from hysterical convulsions by the 
presence of consciousness in the latter, at any rate to a considerable 
extent. Hysterical convulsions in children are not very common, and 
almost never exist without the presence of other symptoms of hysteria. 

Prognosis. — The prognosis of epilepsy for life is, on the whole, favor- 
able, and epileptics may live for many years. 

As regards cure, the prognosis in cases beginning in early infancy is 
very serious. When the disease begins at the age of ten years or later a 
certain number seem to recover, at least temporarily. Many authorities 
consider that true epilepsy is never cured, yet undoubted cases exist in 
which no convulsions take place for years. 

Treatment. — The child should be treated at once, in order to avoid 
continuous shocks to its nerve-centres. Much benefit results from early 
attention to general hygienic conditions and to protection from nervous 
disturbances. The management of these cases demands constant watch- 
fulness and tact, so as to regulate the surroundings of the child in such a 
way as to avoid all source of nervous excitement and irritation, such as 
arise from improper diet, gastric and intestinal disorders, genital irrita- 
tion, and adenoid growths. The diet must be regulated according to the 
especial indications for each patient. A slight gastric irritation apparently 
produces more serious consequences in epilepsy than irritation of any 
other part of the body. A vegetable diet is usually indicated, but when 
the child does not thrive on this it is advisable to give a certain amount 
of meat. Eggs are usually well borne. 

The bromides in some form are, in my experience, the most useful 
drugs. It is often advisable in giving the bromides to change from one 
bromide salt to another, a greater effect being thus produced than by the 
constant use of one of them. Efficacious medical treatment depends for 
the most part on the graduation of the doses, on the selection of the time 
for changing them, and on the determination of the intervals for admin- 
istering them. The best results in using the bromides are obtained by 
diluting the dose with a large quantity of water, 120 c.c. (4 ounces). As 



DISEASES OF THE NERVOUS SYSTEM. 929 

a rule, bromide of potassium has been found to be the most efficient and 
active of the bromides in cases of epilepsy. In giving the bromides it is 
well to begin with small doses, 0.12 to 0.24 gramme (2 to 4 grains), three 
or four times in the twenty-four hours, for the first year, and to double 
this amount for the second year. The dose should be increased gradually 
until the physiological action of the drug is noticed. Tourette has sug- 
gested a very efficient combination in the proportion of two parts of potas- 
sium bromide to one part each of sodium bromide, ammonium bromide, 
and sodium benzoate. Much greater tolerance for the bromides can be 
obtained by omission of salt from the diet. This treatment, at intervals 
of one or two weeks, should be carried on for long periods, and from six 
months to a year after the convulsive attacks seem to have ceased. Cases 
due to traumatic or organic lesions are occasionally benefited by operation. 
The following case represents epilepsy in a girl three years old : 

She was healthy at birth, and remained so until she was two months old. At 
that time she began to have slight convulsive attacks, the cause of which could not be 
accounted for. During the earlier attacks she appeared to be frightened. She would 
then scream, and become rigid and unconscious for about fifteen minutes, after which 
she would sleep three or four hours. These attacks occurred at all hours of the day 
and of the night. They continued at irregular intervals, but were not so frequent after 
the first year and a half. During the first year she seemed as bright as any infant of 
her age, and developed normally. She was treated with the bromides, and they seem 
to have been of some benefit, but did not produce a permanent cure. 

In the third year her mental condition was much affected. She had never been 
able to sit alone or to bear her weight on her feet. She could not feed herself, and she 
understood very little that was said to her. Her head was about the normal size. 
Her face and eyes had a vacant expression, and she had to be taken care of as though 
she were an infant in the early months of life. 

In this case there was no history of epilepsy or of any especial nervous disorder in 
the family, nor of traumatism or of any serious disease which could have produced 
this nervous disturbance. It was a case of chronic epilepsy starting from some un- 
known cause and resulting in permanent idiocy. 

INSANITY. 

Insanity in children is very rare. In the ordinary forms of insanity no 
definite pathological lesion has been found which would account for the 
symptoms presented. Such changes as have been detected come very 
late in the disease and seem to be secondary. In paretic dementia, how- 
ever, we find a special form of cortical interstitial encephalitis. 

Instances of mania and melancholia at times occur. Hallucinations, 
which are a common symptom in the insanity of adults, occur in children 
usually in connection with the delirium of fever, or more rarely with 
epilepsy. Insanity is met with in children at any age ; it is extremely rare 
before puberty, but then becomes more frequent. 

The prognosis of insanity in children varies according to its form. 
Acute mania and melancholia are said to recover generally. True paretic 
dementia is never known to recover. 

59 



930 PEDIATRICS. 

IDIOCY.— IMBECILITY. 

Idiocy is a condition in which there is a complete and permanent im- 
pairment of the mind. Imbecility is a slighter grade of mental deficiency. 
Both conditions occur in brains which are not fully developed in contra- 
distinction to dementia, in which the faculties are lost in a fully developed 
brain. 

Etiology. — Idiocy may be congenital, arising from intra-uterine dis- 
ease, or it may be hereditary in families in whom the parents have had such 
nervous manifestations as insanity, hysteria, epilepsy, and chorea, or who 
have been syphilitic or alcoholic. The acquired form may be caused whea 
there is a predisposition to mental disease or to a cerebral lesion pro- 
duced by traumatic conditions, such as pressure on the head at birth, 
injury to the head by falls or blows, long-continued convulsions, and 
intracranial hemorrhages. Idiocy is in some cases also associated with 
hydrocephalus and microcephalus ; it may also be a result of epilepsy, 
especially when the epilepsy develops early in life and the attacks are 
frequent. 

Acute infectious diseases, especially epidemic cerebro-spinal meningitis, 
are often responsible for the development of idiocy. 

Pathology. — Idiocy is rarely a primary disease, but usually presents 
the terminal lesions of many different diseases of the brain. The result 
of these pathological conditions is usually atrophy, which may be local or 
general, and may be of intra- or extra-uterine origin. Various congenital 
deformities, as those of the lips, palate, mouth, hands, and feet, are fre- 
quently associated with idiocy. 

Symptoms. — The symptoms of idiocy vary according as the individual 
represents a high or a low grade of this condition. An idiot may have a 
large head from hydrocephalus, or a small head from cerebral non- 
development or from cerebral atrophy. Again, idiots may have normally 
developed crania both as to size and as to shape. In the lower grades 
there is often some physical malformation in connection with the mental 
impairment. In the more severe cases of idiocy there is considerable 
incoordination of the limbs, and the movements of the child are awk- 
ward and irregular. In many cases the speech is almost unintelligible. 
The idiot does not take notice of surrounding objects as does the normal 
child, and even when the sight and hearing are perfectly normal the im- 
pressions made on the senses are deadened. Epileptiform convulsions 
very commonly accompany idiocy, and play a most important part in the 
general condition of the patient. 

The symptoms which are usually met with, and which enable us to 
diagnosticate a pronounced case of idiocy, are the vacant expression, the 
occasional presence of strabismus, the drooping head, the drooling, and the 
lack of all idea of cleanliness. The teeth are usually decayed. Sometimes 
the child is so limp that he is unable to bear his weight at all, or will stand 



DISEASES OF THE NERVOUS SYSTEM. 931 

held by the hands, with his feet apart, his knees bent, and his trunk 
leaning forward. The whole body sways to and fro with an oscillating 
movement and absence of equilibrium. When able to walk alone he 
walks in a staggering, uncertain way, and falls easily. In many cases, 
however, the child cannot even sit up alone. The muscles of the neck are 
often so weak that the head falls over on one shoulder or forward on the 
chest. The vertebral column fails to support the trunk and bends to a 
marked degree, and all the muscles are feeble and comparatively useless. 
Lack of power of attention and lack of memory exist in all cases, and in 
the higher grades are often the most prominent symptoms. 

A special type of idiocy has been described under the term agenesis 
corticalis, in which the size and weight of the brain are normal, but in 
which abnormalities of development of the fissures of Rolando, of the 
interparietal fissures, and of the cortical nerve-cells have been recognized. 
This form of idiocy is associated with blindness and terminates in ma- 
rasmus. 

Diagnosis. — We should be careful in very young children not to con- 
fuse slow or retarded mental development with idiocy. There is so much 
variation in the time at which children walk and talk, that a delayed de- 
velopment of these functions must not be considered to represent a con- 
dition of mental impairment. Some children develop so slowly, both 
bodily and mentally, that they appear very backward in comparison with 
others of the same age. Children in the first year of their lives may be 
so seriously affected by some grave disease that their development is pre- 
vented from advancing normally, and in comparison with other children 
of the same age they may be far below the usual grade of intelligence. If, 
however, we examine this class of cases carefully, we see that, although 
they are very backward in their development, they are gradually devel- 
oping, and that they do not represent the condition of complete arrest of 
development which exists in idiots. 

It is well to remember that in rhachitis we are apt to have not only 
retarded mental development, but a weakness of the extremities simulating 
paralysis. When both these conditions occur, such cases may sometimes 
be mistaken for idiots. 

Treatment. — The treatment of idiots is essentially comprised under 
the question of their education. The education of this class of cases 
should be begun early, usually from the fourth to the sixth year. Much 
can be done to improve the various defects which exist in each individual. 
He can usually be taught to co-ordinate his movements, and by attending 
to his general health his physical condition can often be much improved. 
In many cases if convulsions are present they can be more or less con- 
trolled. Malformations or paralyses can be treated with benefit by appa- 
ratus or by operation. The best results in these cases will be attained 
by placing the children in institutions devoted to the training of idiots. 
Parents can be told that the association of their children with others who 



932 PEDIATRICS. 

are feeble-minded is not a disadvantage, while it is often a great disadvan- 
tage for the children of sound mind in a family to be associated with one 
who is idiotic. In the large majority of cases, however, they will always 
have to be supervised during their lives, and, in most instances, after they 
have advanced to a certain point they are liable to retrograde. 

MICROCEPHALTJS. 
When the head is under a certain size it is called microcephalic. The 
size which is usually accepted as representing a microcephalic head is 
from 40.5 to 43 cm. (16 to 17 inches). According to Broca, microcepha- 
lus exists when the brain weighs 1049 grammes (35 ounces) in the male, 
and 907 grammes (30 ounces) in the female. It is generally considered 
that this microcephalic condition is due to a lack of intra-cranial pressure. 
Together with the lack of development of the cranial bones there exists 
in these cases a lack of development or atrophy of the brain, which may 
be considered either as the cause of the lack of intra-cranial pressure or, 
as is still believed by some writers, as the result of the external pressure 
caused by a premature synostosis. Microcephalic children are feeble- 
minded and usually present the symptoms of a somewhat low grade of 
idiocy. They not infrequently show signs of weakness of the limbs. 

MIRROR WRITING. 
An unusual and somewhat striking symptom which at times occurs 
in severe and, as a rule, chronic cerebral disease is one which is called 
"mirror writing,' 1 which is a condition represented by the individual 
writing in such a way that the letters can only be deciphered when they 
are reflected in a mirror. This symptom is usually found when there is 
cerebral degeneration or among the feeble-minded. The actual pathology 
of the affection has not yet been determined. 

HYSTERIA. 

Hysteria is a functional disturbance of the cerebral centres represented, 
according to Mobius, by a state in which ideas control the body and pro- 
duce morbid changes in its functions. The name is a misnomer, but it 
has been adopted so generally that Ave must use it for the present. 

Etiology. — We know very little about the etiology of hysteria. Well- 
marked instances of the disease occur in early life, usually in the middle 
and later periods of childhood. An inherited nervous organization or 
highly exciting surroundings, combined with a lack of proper home disci- 
pline, appear to present as likely a field for the disease to develop in as 
any conditions, such as fright, which apparently, at times, directly lead to 
it. It is a rare disease in children. 

Symptoms. — The mere presence of emotional or imaginative conditions 
in children does not constitute hysteria. For the existence of the disease 
it is necessary to have definite symptoms, either a markedly disorganized 
mental state, paralysis, anaesthesia, or some serious loss of function. 



DISEASES OF THE NERVOUS SYSTEM. 933 

The symptoms are innumerable. Convulsions and paralysis are quite 
common, while dysphagia, amaurosis, and anaesthesia are met with only 
in the very severe cases, and are not often seen in America. Anaesthesia 
is especially interesting as representing a pure type of the disease, and is 
usually on one side of the body. Children perhaps only two or three 
years of age affected by hysteria will sometimes allow themselves to be 
pricked on the anaesthetic side of the face without wincing. 

Hysteria in children as usually seen in America is marked by the 
emotional conditions of the child, and by the presence, in many cases, of 
a fixed idea relating to its own physical condition. The child believes 
that it cannot perform certain actions or functions, and hence does not 
perform them. There probably has often been in the beginning some 
real difficulty or disturbance of the performance of these functions, such 
as pain, which has passed away or which is not sufficient to produce the 
present condition. 

The most common symptoms, aside from the mental condition, are 
convulsions, paralysis, and anaesthesia. 

The convulsions are distinguished from those of epilepsy by the 
absence of loss of consciousness. The patient never seriously injures 
himself in falling, and does not bite his tongue. He does not sleep after 
the attack. 

The paralysis is often of the spastic form, and may be either hemi- 
plegic or paraplegic. In this form the limbs are rigid and the knee-jerks 
are exaggerated. It may, however, be of the flaccid variety, with the 
knee-jerks diminished or absent. It is distinguished from the organic 
forms of paralysis by the normal reaction of the muscles to electricity, by 
the absence of atrophy, by the absence of any affection of the sphincters, 
and at times by the presence of anaesthesia. 

When anaesthesia occurs it is usually irregular in distribution, occur- 
ring in patches, or else it has the same distribution as in cerebral organic 
disease. It is often variable, changing more or less from day to day. 

Although almost any symptom may occur in hysteria, yet the lack of 
uniformity in the grouping of the symptoms, and the combination of symp- 
toms which belong to entirely different diseases, are of great aid in making 
the differential diagnosis from these diseases. 

We sometimes meet with an exaggerated hysteria in children. The 
attacks are represented by screaming, running, jumping, and a feeling of 
being pulled about ; they may last for hours, or for days ; their duration, 
however, is usually long, — at times, with intervals, over a year. No signs 
of organic disease are found in these cases ; they seldom injure them- 
selves, and are finally cured by moral influence, change of scene, and 
good hygienic surroundings. 

Hysteria occasionally causes children to present symptoms of serious 
disease of the spine and joints. This most often follows some slight 
injury, but may occur spontaneously. 



934 PEDIATRICS. 

Prognosis. — The prognosis in cases of hysteria is, as a rule, favorable. 

Diagnosis. — Generally, the diagnosis is not so difficult as in adult life, 
because the child is not able to control its sensations of pain and fear so 
completely as is possible with adults. In surgical cases, however, in 
which hysterical affections simulate most closely organic disease of the 
joints, the diagnosis is often attended by extreme difficulty. The applica- 
tion of strong currents of electricity will usually show that the anaesthesia 
is not real. 

Treatment. — The treatment of hysteria is to break up at once the 
harmful home surroundings, if such exist, and by means of gentle but 
firm compulsion to make the child understand that its symptoms are 
unreal. The various local symptoms connected with the digestion and 
general health of the child should be carefully treated, as the hysterical 
symptoms are often largely dependent on conditions of this nature. 

The following case represents hysteria in a girl ten years old : 

The history of the case was that her parents were living and well, and that there were 
a number of other healthy children in the family. This child had always been well 
until eighteen days before she entered the hospital. At that time • she complained of 
headache, and on going to school returned feeling sick and apparently unable to speak. 
She was said to have been unconscious at times, to have had spasms, and to have been 
very restless at night. She evidently had had great lack of care in her home life, and 
had been given only poor food. She showed the evidence of this lack of care in the 
condition of her skin and her digestion on entering the hospital. A physical exami- 
nation showed nothing abnormal in connection with the thorax and abdominal organs. 
The pupils were slightly dilated, but were equal and reacted to light. The knee-jerks 
were decreased. There was no ankle-clonus. She was apparently unable to walk, 
and she lay in bed taking no notice of anything, but winked her eyes if anything was 
thrust towards them. Her hearing did not seem to be especially impaired. She lay 
in a very limp condition, with the legs drawn up in various positions. Her head 
kept rolling from side to side, and occasionally was retracted. When asleep her head 
was retracted so as to make nearly a right angle with the body. It was difficult to feed 
her, and she would not swallow. Her temperature was 37.2° C. (99° F.), her pulse 
66, and her respirations 16. When being examined she cried out a great deal. 

She was given plenty of good food, and in three or four days her condition was 
much improved. She took her food well, but was apparently unable to feed herself. 
A few days later she showed more intelligence, and on being taken up and dressed it 
was found that she could sit alone and could walk a little with support. On beginning 
to walk she threw her legs about wildly, but after being scolded she walked much 
better. At one time when she was sitting quietly in a chair the visiting physician 
came into the ward, and she immediately allowed herself to slip from the chair and 
roll onto the floor, but evidently was careful not to hurt herself. She at this time cried 
out a great deal, but stopped when no notice was taken of her. She was still unable 
to speak, and, although she could sit up in a chair, apparently noticed nothing. 

Nineteen days after entering the hospital she appeared much brighter, and began 
to take a slight notice of what was going on about her. When questioned, she moved 
her lips as if about to speak, but made no sound. She continued to improve slowly, 
and a few days later said " sister, " understood what she was told to do, and attempted 
to do it. She also walked three steps without being assisted. Some days later it was 
found that she would repeat almost any word that was said to her, but in a whisper. 
After this she improved rapidly and began to articulate fairly well, but slowly and with 



DISEASES OF THE NERVOUS SYSTEM. 935 

an effort. She also spoke voluntarily two or three times. She could not walk without 
assistance, as she would put her foot too far forward. She had been very much con- 
stipated through the whole attack, but at this time the constipation grew less. A defi- 
nite training of the arms and legs was then begun by means of passive movements and 
massage. Under this treatment she greatly improved, and on the thirty-fifth day from 
the time when she entered the hospital, recovered completely. 

HYPNOTIC STATE. 
The hypnotic state is an artificial mental condition which can be pro- 
duced in children as well as in adults. It is supposed to be a temporary 
abeyance of the powers of the higher cerebral centres. In the ordinary 
cases the child is throAvn into a condition in which the consciousness of 
his external surroundings is lost. This condition in outward appearance 
closely resembles sleep, but is produced artificially and can be artificially 
removed. Thus, the sensation of pain can be temporarily abolished, at 
least to a considerable extent. For this reason it has been supposed that 
it might be useful in the treatment of cases requiring minor surgical oper- 
ations. It has also been advocated by some physicians as a form of treat- 
ment in various diseases ; but our experience at the Children's Hospital 
has proved it to be inefficient. 

CATALEPSY. 

Catalepsy is only a symptom. It denotes a condition, apparently of 
cerebral origin, in which, together with total or partial loss of conscious- 
ness, the limbs assume a peculiar form of rigidity called waxy, and remain 
for a considerable time in any position in which they may be placed. It 
occurs at all ages, but is very rare in childhood. The youngest case that 
I know of is that of a little girl three years old, reported by A. Jacobi. 

The prognosis and treatment are those of the primary disease. There 
is no especial treatment for a single attack. 

SIMULATED DISEASES. 

On the boundary-line between children who evidently are suffering 
from the need of judicious discipline and those who may be said to have 
the definite disease hysteria, is a class of cases in which simulation appears 
to play an etiological part. These children are usually in the later period 
of childhood, and seem to have such perverted functions of their nervous 
centres as actually to represent pictures of diseases which are easily proved 
not to be present. Deafness, blindness, pains of all varieties, palpitation, 
dyspnoea, vomiting, spasmodic attacks of various kinds, and many other 
symptoms arise, and may persist for long periods. 

The best treatment for these cases is at once to show the child that 
its symptoms are unreal and of no importance. 

INSOLATION. 
Heat-insolation, or heat-stroke, is a condition apparently represented 
by a functional disturbance connected with the cerebral circulation and 



936 PEDIATRICS. 

produced by heat. This affection in varying degrees is of somewhat fre- 
quent occurrence in children, and is supposed to be accompanied by a 
hyperemia of greater or less intensity of the meningeal blood-vessels, with 
general venous congestion throughout the body. It is met with most com- 
monly in the middle period of childhood, because at that age the child is 
most likely to be exposed to the influences which produce it. 

Symptoms. — The clinical picture of this class of cases is, as a rule, quite 
characteristic. The child has perhaps been playing on a hot summer's 
day somewhat more vigorously than usual, possibly romping with an older 
child of more highly developed nervous resistance, getting intensely ex- 
cited, and greatly overtaxing its muscular strength. It may be that it has 
been exposed to the direct rays of the mid-day sun, or it may have been 
playing in some covered but heated and stifling place. The child's nurse, 
noticing the extremely flushed condition of its face and head and its 
excited, sparkling eyes, takes alarm and hurries it to its home. Intense 
headache soon comes on, and in a few hours delirium may supervene. 
The skin is hot, dry, and reddened ; there may be vomiting in the begin- 
ning ; the carotids and temporal arteries throb perceptibly. The heart's 
action is violent, and the temperature is raised to 38.9°-39.4°-40° C. 
(102 o -103°-104° F.); the pulse is much accelerated, perhaps 140 to 
150, and is full, but usually rhythmical. The conjunctivae are congested 
and the pupils contracted. Photophobia to a greater or less degree is 
almost invariably present. Beyond this there may be no symptoms ex- 
cept a slight amount of muscular twitching, and in some cases a convul- 
sion may occur if the temperature runs as high as 40° to 40.6° C. (104° to 
105° F.). The temperature, however, in accordance with the rule in this 
disease as in others Avhich occur in children, does not always produce the 
same or equally severe symptoms. Convulsions may occur as a very 
common form of nervous explosion when fever and disturbance of the 
cerebral circulation are present, but, as a rule, this symptom is absent. 

Prognosis. — We should be careful as to the prognosis given in these 
cases. Although they often simulate closely a beginning meningitis, yet 
they are very amenable to treatment, and should therefore be carefully 
differentiated from that disease. In very severe cases the children may, of 
course, die of insolation. 

Diagnosis. — The diagnosis from meningitis is based upon the history, 
the milder grade of the symptoms, except the headache, and finally, in 
doubtful cases, on the rapid recovery and speedy disappearance of the 
fever. 

Treatment. — The treatment of heat-insolation with severe symptoms 
and high temperatures should be prompt and vigorous. A stimulating 
enema of salt, one teaspoonful to a quart of cold water, should first be 
given. The child should then be placed upon a bed protected by a rubber 
sheet in a cool, darkened room ; a warm mustard pack should be applied 
to the lower extremities, and the neck and chest gently sponged with 



DISEASES OF THE NERVOUS SYSTEM. 937 

water at 25° C. (77° F.) for fifteen minutes out of every hour. Letter's 
coil should be applied to the head with water at 5° C. (41° F.) ; bromide 
of potassium should be given, 0.3 gramme (5 grains) every hour for four 
doses ; a little iced milk may be taken if the child cares for it, not more 
than one or two ounces at a time ; and complete rest and quiet for at 
least twenty-four hours are usually indicated. Stimulants by mouth and 
subcutaneous injection should be given when needed. The child should 
be watched carefully for some days and not allowed to play actively 
enough to get heated. Great care should be taken for the rest of the 
summer to protect the child from the direct rays of the sun, as after one 
attack the cerebral circulation remains in a very sensitive condition for a 
considerable period. 

Mild cases occur which do not call for such vigorous treatment. Rest 
in bed, small doses of brandy or aromatic spirits of ammonia, and a light 
diet of milk and lime-water are all that is required in these cases. 

CONCUSSION. 

By concussion we mean clinically a group of symptoms following 
some physical shock, with its resulting traumatic irritation of the nervous 
centres. I have met with a number of instances of this nervous phe- 
nomenon. The symptoms are indefinite, and are usually ascribed to the 
brain as the seat of irritation. 

The treatment of a case of this kind is simply by perfect rest and 
quiet in a darkened room, with hot applications to the feet and abdomen, 
and small and repeated doses of stimulants given by enemata until the 
stomach is able to retain them, the treatment being continued until the 
circulation is normal and the pulse strong. 

TEMPORARY AMNESIA. 
The following case of temporary amnesia represents a class of nervous 
disturbance the pathology of which we know nothing of and the causes 
of which are manifold : 

A boy, thirteen years old, while running struck his head against a tree. I saw 
him three hours later. He had walked home, but was a little nauseated, and was put 
to bed. I found that he had partial loss of memory and was drowsy, but that he had 
no especial pain. He was perfectly well on the following day. 

TEMPORARY APHASIA, 
An instance of suspension of the cerebral function connected with the 
elaboration of words is illustrated by Demme's case. 

A child, six years old, previously well and bright, suddenly lost the power of 
speech. This phenomenon occurred during an operation for talipes, which was being 
performed without an anaesthetic. After the operation the child was perfectly well, 
but was unable to elaborate words until the ninth day, when she began to use the one 



938 PEDIATRICS. 

word " mamma" for everything that she wanted to say. She then gradually increased 
her vocabulary until the twenty-first day, when her aphasia disappeared entirely, and 
she developed mentally and physically in a normal manner. 

ARRESTED PSYCHICAL DEVELOPMENT. 

Arrested psychical development is a term used in speaking of an ap- 
parent lack of mental growth which is sometimes met with in infancy. 
So far as we know, it is a functional and not an organic condition of the 
brain. Infants with this affection develop both mentally and physically 
for a variable period, perhaps five or six months, and then continue to 
develop physically but cease to develop mentally. This condition lasts 
for a variable period of months, when their mental development begins 
again, and, although for some time they are backward in comparison with 
other children of their age, they finally show no trace of an abnormal 
mental condition. 

In some cases the arrest of cerebral development is associated with a 
condition of physical weakness, so that the power to sit and to walk at the 
usual age is delayed to a much later period, as the third or fourth year. 

Arrested psychical development seems to be rather commonly asso- 
ciated with rhachitis, and may also occur in the course of severe illnesses, 
but nothing else is definitely known concerning it. 

RETARDED SPEECH. 

When during the second year the power of speech does not develop 
with the usual rapidity, it is spoken of as retarded speech. 

This lack of power to speak may be from a simple lack of develop- 
ment of certain portions of the brain, or from organic or functional cere- 
bral disturbance. It may also arise from abnormal conditions outside of 
the brain. The cases which are caused by a lack of development may 
be of congenital origin, or may be due to an arrested cerebral develop- 
ment produced by a number of causes. These causes are usually con- 
nected with some serious interference with the cerebral growth, such as a 
severe illness. Organic aphasia is like that produced by some organic 
lesion of the brain such as exists in cases of cerebral paralysis. It may 
also be connected with the condition of idiocy. The functional aphasia 
I have already described. It may be produced by many causes, among 
others the infectious diseases. A child may for a time during a severe 
illness, and after convalescence has been established, apparently be unable 
to use the words that it was accustomed to before the illness. I have in 
a number of cases, however, noticed that the child speaks better than it 
did before the illness. 

Retarded speech may also be caused by such physical defects as dis- 
ease of the ear resulting in deafness, and from such a physical malforma- 
tion of the mouth, palate, or vocal cords as to render articulation impossible. 
In this connection stammering may be spoken of as a cause of retarded 
speech. When called upon to decide why the child is unable to speak, 



DISEASES OF THE NERVOUS SYSTEM. 939 

the previous history should be carefully investigated. In this way organic 
disease of the brain can be eliminated by means of the absence of the 
usual symptoms of such disease, especially hemiplegia, and by ascertain- 
ing that the child has not had any disease sufficiently severe in its char- 
acter to interfere with the development of the centres of speech. After 
determining that the child is not an idiot, the ear and mouth should be 
examined. If the child is deaf, there is a good reason for his not being 
able to speak. Even when young children have learned to speak fairly 
well, if they later become deaf from a disease like scarlet fever, they are 
very apt to become .mute also. When a lesion of the ear has occurred 
before the child has learned to speak, he almost invariably is found to be 
a deaf-mute, although there may be no defects in articulation or in his 
mental condition. It is seldom that any defect in the mouth or throat is 
found which interferes with articulation, except in cases in which very 
extensive lesions are present, such as cleft palate, and sometimes enlarged 
tonsils combined with a high-arched palate and a large adenoid growth. 
The tongue-tie which the parents usually consider to be the cause of 
the retarded speech is seldom present. When no symptom of organic, 
functional, or developmental cerebral disease exists, when there is no 
physical deformity, and when the child hears well and seems bright and 
well developed in other ways, the parents, as a rule, may be assured that 
the speech is merely retarded and will probably develop later. 

HEADACHES. 

When pain in the head occurs in early life it is to be regarded more 
seriously than at a later period, as it is more apt to indicate some grave 
central lesion. The various forms of organic headache which arise in 
children can be spoken of best as symptomatic of the various diseases in 
which they occur. 

There also appears to be a type of headache which occurs in the later 
years of childhood irrespective of any definite disease and is often unac- 
companied by nausea. These headaches, as a rule, are not of serious 
import, and are usually classed under the term functional. They occur 
irregularly, and may be in any part of the head. They are often so 
severe that the child has to lie down. The intervals between the attacks 
are variable, and the length of the attacks varies from two to three hours 
to a day. Of these functional headaches the most frequent form in chil- 
dren is that due to anaemia. It is always, however, wiser to look upon 
this form of headache as a symptom of some undetermined disease. 

Although in many cases headaches are caused by an improper regula- 
tion of the diet, yet there is evidently some other cause which we do not 
recognize in their production, as with exactly the same diet for many 
months a child will show no symptoms Avhatever of headache. In like 
manner, although we know that headaches in children may depend upon 
constipation, yet this class of cases occurs whetner constipation is present 



940 PEDIATRICS. 

or not. The source of the headache cannot be determined by the part 
of the head affected. 

Migraine also may exist in children, and is characterized by severe pain 
in the head, sometimes unilateral, sometimes bilateral, accompanied by 
nausea, dizziness, and generally vomiting. The attacks occur at irregular 
intervals, and usually last the greater part of a day. They may be brought 
on by apparently slight causes, such as over-fatigue, eye-strain, or very 
mild indiscretions of diet, in those predisposed to them. These head- 
aches are markedly hereditary. 

Although all these forms of headache are ordinarily very intractable 
to cure, especially when no bad hygienic surroundings exist which might 
account for them, and when the child does not lead a sedentary life, yet, 
as a rule, the attacks have a tendency to lessen and disappear as the 
child grows older. 

One of the most common causes in children is pain caused by strain 
of the eyes. In all cases of headache in children the cause of which is 
not evident, a careful examination of the eyes should be made, even 
though there be no symptoms which point to the eyes themselves. 

Treatment. — The treatment of headache should be directed to that 

of the disease which is causing the disturbance when it can be detected, 

as in anaemia or hyperemia from various causes, gastric disturbances, the 

prodromal stages of the acute infectious diseases, malaria, uraemia, and 

other toxic causes ; when, however, no cause can be found, a darkened 

room and sufficient bromide of soda to allay pain and produce sleep are 

indicated. 

VERTIGO. 

Vertigo at times occurs in children. It is a term applied to a condi- 
tion in which the individual or the objects around him appear to be roll- 
ing about. It is called subjective vertigo when the patient himself seems 
to be turning, and objective vertigo when it is the surrounding objects 
that appear to move. 

Vertigo has a variety of causes. It may be due to organic cerebral 
diseases, such as tumors of the brain, especially of the cerebellum, and 
to diseases of the ear and of the eye. It may also be due to circulatory 
disturbances, as in cardiac disease, and to the stomach, as from improper 
food, also from tobacco and tea. 

The following case illustrates this condition : 

A boy, thirteen years old, had had a purulent otitis for several years, but this had 
healed three years previously, leaving a condition of adhesions and cicatrices with con- 
siderable impairment of hearing, but with no trouble of the labyrinth nor any symp- 
toms pointing to it. 

He was always strong and well until he was seven years old. At ten years he 
began to have attacks of dizziness accompanied by seeing white spots. At times he 
had nausea. A sensation of spinning around or falling subsequently developed, was 
constant, and increased in severity. He had no other abnormal symptoms except 
weakness. He slept well, his appetite was fair, and his bowels were regular. He had 



DISEASES OF THE NERVOUS SYSTEM. 941 

good hygienic surroundings, did not smoke, and had never lived in a malarial district. 
He was a close student and led a sedentary life. He had never had any headache. He 
drank much tea. He was directed to stop drinking tea and to ride on horseback. 
Within a few weeks after the active exercise had been begun and the tea had been 
omitted from his diet, the boy ceased to have attacks of vertigo. 

PAVOR NOCTURNUS. 

The night-terrors of children may occur from a variety of causes, and 
should not be considered as one disease, but as a symptom of a number 
of diseases. Any nervous disturbance, whether central or peripheral, 
may produce so profound an impression on the sensitive cortical cells of 
the brain that the child's sleep may be disturbed by a cortical irritation. 

The following case represents the special form of pavor nocturnus 
which may be considered central : 

A boy, six years of age, had always been a delicate, thin, pale child, not caring 
much for out-of-door exercise, but inclined to remain in the house and to be read to or 
to have exciting stories told to him. His appetite was poor. He was mentally bright 
and precocious. Otherwise he appeared to be well, and showed no signs of any organic 
disease. One evening he was allowed to sit up rather later than usual, and a number 
of terrifying stories were told to him. He went to sleep as usual, but in about an 
hour waked up screaming. He was found sitting up in bed looking terrified. His eyes 
were staring at some invisible object, evidently a picture in his brain and not a reality ; 
he was pointing at this imaginary source of his terror, and kept repeating that it was a 
black dog. It was impossible to pacify him for about ten minutes, and he did not 
recognize his mother during the attack. He then became more quiet ; the wild look 
passed from his eyes ; he recognized his mother, and soon lay down and went quietly 
to sleep. The cause of this attack, which is typical of the central form of pavor noc- 
turnus, was evidently an undue excitement of the cells of the cortex in a bright, nervous 
child before going to sleep. The treatment of a case of this kind is to accustom the 
child to more exercise in the open air, to prevent his reading anything but the most 
ordinary and simple books, and to have no stories whatever related to him, especially 
at night. 

The following case represents the peripheral form of pavor nocturnus : 

A girl, three years old, had been always well and strong ; she had a good appetite ; 
was not nervous or excitable ; she was fond of playing out of doors, and was not fond 
of having stories told to her. She was constipated, and had a tendency to overload her 
stomach. She had eaten a very heavy supper, and on going to bed immediately fell 
asleep, but soon began to be restless, to throw herself about, to groan, and to grind 
her teeth. A little later she woke up screaming, and apparently had a certain amount 
of dyspnoea. She did not recognize her mother, but sat up in bed looking very much 
frightened and clutching at her throat. Her mother made her drink some warm water, 
which produced copious vomiting. She then became rational again, recognized her 
mother, and soon lay down and went to sleep. She had no recollection of the attack on 
the following day. 

The irritation in this case was of the terminal filaments of the pneumogastric 
nerve in the stomach, causing reflex symptoms of the nervous centres to such an extent 
that the child was terrified and felt as though she would stifle. 

The treatment in cases of this kind should be by moderating the diet and allow- 
ing the child to have only a light and digestible supper. The two classes of cases are 



942 PEDIATRICS. 

distinct and their treatment is entirely different. A mixture of both of these forms is 
frequently met with, between which it is not possible to make a clear distinction. 

TREMOR. 
Universal or partial tremor is rare in infancy and in early childhood in 
comparison with later life. It does, however, occur, and is usually sig- 
nificant of an organic cerebral lesion. I have noticed it also in cases of 
infantile atrophy, in which as recovery gradually took place the tremor 
disappeared. In this form it appears to be chiefly a symptom of weak- 
ness. It may be quite marked as a general symptom, but it is not espe- 
cially signilicant, either in respect to the diagnosis or to the prognosis. 

TETANY. 

With the knowledge which we have at present of this condition we 
must look upon tetany as a symptom of nervous irritation and not a defi- 
nite disease. The condition is represented by tonic intermittent paroxysmal 
muscular contractures varying in duration and intensity. Although the 
seat of these contractures may be in other parts, such as the neck, face, 
and thorax, yet the chief and characteristic parts are the hands and arms, 
legs and feet. The wrist is sharply flexed and turned outward ; the thumb 
in the position of extension is drawn across the palm of the hand beneath 
the fingers, which are flexed at the metacarpophalangeal joints, but other- 
wise are in the position of extension. The feet are rigidly extended and 
may be in the position of talipes equinus or of equino-varus. The pha- 
langes of the toes are flexed and extended in the same way as those of 
the fingers. Tetany as a term should be used only when these character- 
istic contractures are present, and should not be applied to other condi- 
tions of increased reflex excitability. Opisthotonos may occur. The knee- 
and hip-joints are usually not affected. 

Etiology. — Tetany is a symptom of a number of different conditions, 
and is not pathognomonic of any one disease. It is at present believed 
that certain toxins may be developed which affect the central or periph- 
eral nervous system. This is especially liable to occur in gastro-enteric 
diseases, in rhachitis, in various acute diseases, such as pneumonia, and 
especially where the hygienic surroundings are bad. 

Pathology. — There is no definite morbid condition with which tetany 
is associated. The condition is functional rather than organic. It is gen- 
erally accepted that certain forms depend on the loss of the function of 
the thyroid gland. 

Symptoms. — The peculiar spasmodic conditions described above vary in 
their duration, and are usually paroxysmal. They may last only a few 
minutes or for hours or even days. Pain is at times present, especially 
when the attempt is made to overcome the spasm. The temperature and 
pulse, according to the exciting disease, are increased. The electrical ex- 
citability, mechanical excitability, cutaneous reflexes, and knee-jerks are 
increased. 



DISEASES OF THE NERVOUS SYSTEM. 943 

Trousseau's symptom (compression of the large nerve-trunks or blood- 
vessels of the parts affected bringing on the paroxysms) is generally present, 
and in some cases Chovstek's symptom (active contraction of the muscles 
supplied by the facial nerve produced by a slight tap on the course of the 
nerve) can be obtained. Laryngo-spasmus occurs in certain cases, espe- 
cially when rhachitis is present. When the muscles of the trunk are 
involved, dyspnoea, cyanosis, and even opisthotonos may occur. 

Diagnosis. — The peculiar bilateral spasms usually occurring in the 
course of such diseases as rhachitis or gastro-enteric disturbance, espe- 
cially when combined with Trousseau's and Chovstek's symptoms, serve 
to distinguish true tetany from other nervous manifestations of muscular 
irritability. From tetanus the diagnosis is made by the absence of trismus ; 
from meningitis by- the absence of cerebral disturbance ; and from cerebral 
tumor by the bilateral spasm and absence of headache. 

Prognosis. — The symptom in itself is not a serious one, the danger 
depending upon the gravity of the special disease which is causing the 
tetany. 

Treatment. — The general nutrition of the child should receive careful 
attention. Hot baths, chloral, the bromides, and electricity are indicated, 
and the endeavor should be made to remove the especial cause, which is 
frequently to be found in the gastro-enteric tract. Thyroid extract should 
be tried when no primary cause for the tetany can be determined and 
other treatment is found to be inefficacious. 

DENTAL REFLEXES. 
The twitching which occurs in children at the time when a tooth is the 
apparent cause of a certain amount of discomfort and fever should be 
referred to here as a significant illustration of nervous phenomena from 
reflex causes. The cases are numerous, but scarcely of sufficient impor- 
tance to report. In certain instances, however, convulsions of a reflex 
nature occur at this time and cease when the tooth has assumed its place 
above the margin of the gum. I have also met with some interesting 
cases of local oedema arising during the period of dental irritation, and 
usually spoken of as angio-neurotie oedema. 

One of these cases was a male infant, fifteen months old, who some months pre- 
viously, while cutting one of the second molars, had an attack of oedema of the hands, 
which was not accompanied by irritation or any other symptom, and which passed off 
after a few hours. 

This same boy when the canine teeth were about to come through the gums was 
again attacked by oedema of the face. This local oedema, as in the previous instance, 
disappeared quickly. 

At times I have seen a local oedema attacking one eyelid, so that the 
eye could not be closed. 

Although we cannot say that irritation from the teeth is necessarily 
the cause of these conditions, yet they so often arise during the dental 



944 PEDIATRICS. 

period, and not during other periods of childhood, or before the fourth or 
fifth month, that we can at least say that in individuals of an excessively 
nervous temperament the irritation which evidently arises in certain cases 
when the teeth are developing may be sufficient to cause a nervous explo- 
sion, which in this sense may be spoken of as of dental origin. 

NYSTAGMUS. 
By nystagmus is meant a peculiar rhythmical oscillation of the eye- 
balls, usually from side to side, but in some cases up and down. It may 
sometimes be dependent on organic disease of the brain, and again may 
arise from local diseases of the eye, so that a careful examination of the 
central nervous system and an expert examination of the eyes should 
always be made. In many cases, however, this condition appears to be 
purely reflex from various peripheral stimuli, and is not a very uncommon 
symptom in young children. I have notes of two cases, brothers, who 
during the dental period showed this oscillation of the eyeballs with no 
other symptoms. Complete recovery resulted when dentition Avas com- 
plete. The cause, however, of the reflex irritation must always be 
looked for, and it must not be taken for granted that the chief etiological 
factor is dentition, for in many cases disturbance of th,e gastro-enteric 
tract is present. 

GYROSPASM AND SPASMUS NUTANS. 
Gyrospasm (rotary movements of the head) and spasmus nutans 
(nodding) are peculiar movements of the head in young children which 
are apparently of reflex origin, and are at times associated with nystag- 
mus and strabismus. The chief causes are rhachitis, gastro-enteric irrita- 
tion, and dentition. The prognosis is usually good except when idiocy 
is present. The best treatment is with the bromides. 

REFLEX SYMPTOMS OF THE EAR. 
The reflex connection between the roots of the teeth and the mem- 
brana tympani by means of the otic ganglion produces the well-known 
reflex earache which occurs during the dental period. This has been 
described on page 634. 

REFLEX SYMPTOMS OF THE LARYNX. 

In certain cases reflex symptoms occur in the larynx. They are 
usually noted during infancy rather than in childhood. The affection has 
been called laryngospasmus, and although it is more usual for it to occur 
in rhachitic children than in others, it is not necessarily confined to 
rhachitis. It is not in my experience a very common disease, but when 
met with it is very characteristic. 

Symptoms. — The infant is suddenly attacked by an inspiratory or ex- 
piratory spasm of the larynx. This condition may be precipitated by 
various causes, such as fright and excitement. I have also seen it produced 



DISEASES OF THE NERVOUS SYSTEM. 945 

by various peripheral irritations, such as those of the nose. At times the 
attack is so severe that the infant becomes unconscious and cyanotic. The 
attack lasts for only a few minutes, and on recovery the infant seems as 
well as ever. There does not seem to be an inflammatory condition con- 
nected with this symptom, and apparently it is purely of a reflex nature. 
In some cases a crowing laryngeal sound will frequently precede and often 
succeed the more severe stage of the attack. 

Prognosis. — The prognosis in cases of laryngospasmus is, as a rule, 
favorable, although very weak infants may die in an attack. 

Treatment. — As the infants are usually delicate and of a highly ner- 
vous organization, the treatment should be directed to improvement of 
their general health and to protection from nervous excitement until they 
have attained an age when their nervous system is less irritable and is in 
more stable equilibrium. During an attack the treatment is to endeavor 
to produce relaxation of the spasm by peripheral irritation elsewhere. 
This is usually done by showering the child on the chest and face with 
cold water and lightly slapping the back. 

Among a number of cases of this kind which have come under my 
notice was this one : 

A boy, one year old, had always shown a nervous temperament and had had a 
number of convulsions when he was cutting his first teeth. With the exception of a 
light attack of epidemic influenza, he had been well and strong. Following the attack 
of epidemic influenza, in which the nasal symptoms were prominent, he was left with 
a very irritable naso-pharynx. He then began to have attacks characterized as 
follows : 

Whenever the nurse, while giving him a bath, attempted to cleanse his nose, no 
matter how gently, he would immediately gasp, with a catching sound in his breath- 
ing, become rigid, draw himself back sometimes almost to the position of opisthotonos, 
become unconscious and cyanotic, and then after a few seconds the spasm would pass 
away and he would seem perfectly well again. These attacks continued for some 
months without apparently harming him, and they then grew less frequent and passed 
away entirely. 

As additional examples of reflex phenomena of the larynx having 
their origin in the ear may be mentioned the hoarseness which sometimes 
accompanies the impaction of cerumen in the ears, and which disappears 
almost immediately after the removal of the mass. Blake reports a case 
in which a persistent laryngeal cough of several months' duration was 
immediately relieved by the removal of a bead from the external auditory 
canal. These cases, as well as those in which there is a reflex cough, 
can be explained by means of the following diagram, which shows the 
reflex connection between the ear and the larynx. 

The irritation of the sensitive fibres of the auriculo-pneumogastricus 
distributed in the meatus and in the membrana tympani is reflected 
along the motor fibres of the superior laryngeal nerve, exciting in the 
larynx the act of coughing by causing contraction of the crico-thyroid 
muscle. When the original irritant, either in the meatus or in the mem- 

60 



946 



PEDIATRICS. 



brana tympani, by its continued presence involves the vaso-motor fibres 
associated with the auricular nerve, they conduct their impression to the 
ganglion of the pneumogastric, and thence it is deflected through a sympa- 
thetic fasciculus proceeding from it to the first cervical ganglion. This 

Fig. 190. 

• (s> : --^-~. 



/ 


% » 


1 J 


| 


/ H^d 








/ /s 


• x 


L 


c 




b 



';© 



Reflex connection between the ear and the larynx. A, auditory canal, membrana tympani, and 
middle ear ; B, second ganglion of vagus ; C, first cervical ganglion of sympathetic ; D, auriculo- 
pneumo-gastric nerve ; E, sympathetic fasciculus connecting B and C ; F, nervi molles, vasomotor 
connection with external carotid ; G, external carotid ; H, laryngeal artery ; S, superior laryngeal 
nerve ; L, larynx. 

again through the nervi molles carries the impression to the external 
carotid artery, and by its branches to the mucous membrane of the 
larynx, and as a result of reflected vaso-dilator impressions we may have 
congestion of the vessels supplying the mucous membrane of the larynx, 
and perhaps effusion from these vessels. 

The detailed description of the anatomical conditions underlying these 
reflex phenomena will be found on page 634. 



PAROXYSMAL GASPING. 

A condition known as paroxysmal gasping occasionally occurs in 
young children. 

The child, previously quiet, suddenly becomes cyanotic, rolls up its 
eyes, stops breathing, gasps, and looks as though it were about to die. 
The seizure is apparently a reflex irritation of the diaphragm, and could 
be classed under hysteria. These cases respond quite readily to good 
care, well-regulated food, and relief from the duties of school. In some 
cases there are no serious symptoms, but mere gasping of light grade. 

REFLEX SYMPTOMS OF THE LUNG. 
In young infants pulmonary attacks closely simulating the symptoms 
of asthma occur from gastric irritation of the terminal filaments of the 
pneumogastric nerve. They are evidently reflex in their character, and 
are promptly relieved by treatment of the stomach. They are spoken of 
under the term asthma dyspepticum. In cases of this kind it is usually 
found that the peripheral irritation either arises from the too high per- 
centages of the solid constituents of the milk which is given to the infant, 



DISEASES OF THE NERVOUS SYSTEM. 947 

or is caused by the total amount of milk given being too great for the 
infant's gastric capacity. 

Symptoms. — The first symptoms noticed in these cases are the pallor 
of the infant's face, and a slight cyanosis around the mouth. The respi- 
rations then become quickened, and the infant is evidently in great dis- 
tress. It becomes cyanotic, breathes very rapidly, and often looks as 
though it were about to die. On examining the chest the lung is found 
to be resonant, and there is nothing abnormal on auscultation except 
roughened respiration and a few sonorous rales. 

Treatment. — An emetic will quickly relieve this condition, which disap- 
pears as soon as the stomach is emptied. The attacks are sudden and often 
recur. After the attack has passed off, the abnormal sounds heard in the 
lung are found to have disappeared completely, and the infant seems per- 
fectly well again. 

Another class of reflex pulmonary symptoms which has at times come 
under my notice consists of cases in which, from some peripheral irritation 
elsewhere, marked pulmonary symptoms simulating pneumonia arise. 

The first case was a little girl six years old. The first attack occurred at a time 
when she was having an exacerbation of an attack of subacute purulent otitis media. 
She had a heightened temperature, 40° C. (104° F.), and rapid respirations (60 in a 
minute). The alae nasi were moving slightly, and she showed a certain amount of or- 
thopnea. Her face was flushed, and she had a short, dry cough. She had a discharge 
of pus from both ears. On looking at this child one would naturally have said that 
she had pneumonia. Evidence of this was given by the temperature, the respirations, 
the alae nasi, the cough, and the orthopnea. The lungs, heart, and throat were found 
on examination to be normal. The pulmonary symptoms were evidently reflex in their 
nature, as it is believed that in these cases the reflex symptoms are usually produced 
by the occlusion of the Eustachian tubes. 

On inflating the Eustachian tubes with the air-douche her breathing became nor- 
mal in rate, 24 to 28 in a minute, the alae nasi ceased to move, the cough disappeared, 
and the child could lie down with comfort. 

REFLEX COUGH. 
The nervous connection between the ear and the larynx gives rise at 
times when there is disease of the former, such as an otitis media, to a 
persistent cough, which is evidently reflex, and which is relieved only by 
treatment of the ear. 

A little girl, four years old, had an attack of measles which was complicated by an 
otitis media. She recovered entirely from the measles, and seemed perfectly well, 
except that the perforation of the membrana tympani had not entirely healed. Some- 
what later the cough began. Nothing was found to account for this symptom in the 
throat, lung, or larynx, except a slightly reddened appearance of the latter from cough- 
ing. The cough was intractable to all local treatment until the ear, which had been 
in the process of healing, again showed signs of increased inflammation. Whenever 
the ear was discharging, the cough ceased entirely. When the ear was treated and the 
discharge grew less, the cough began again, and there was an evident reflex connection 
between the larynx and the ear. 



948 PEDIATRICS. 

These reflex phenomena continued for some months, the child always coughing 
when the ear got better and ceasing to cough when the ear got worse. Finally, on 
the child's being taken to Switzerland and having an entire change of air, its general 
health was much improved, and the reflex cough passed off. There was no recurrence 
of this condition in the following ten years. 

When there is an irritation in the nasopharynx a reflex cough often 
occurs, and is best treated by local applications to the pharynx and naso- 
pharynx. It is. important for the physician to recognize this class of 
coughs, as he might otherwise be very unsuccessful in treating these cases. 
Many children are treated with drugs for a cough which is usually ascribed 
to bronchitis, where no physical signs of irritation can be found in the 
lung, larynx, or throat, and where the irritation is in the nose or the naso- 
pharynx. In place of the many drugs usually given in these cases, a 
simple spray in the nose is indicated. 

REFLEX SYMPTOMS OF THE HEART. 

Cases of extreme palpitation in children are occasionally met with 
when nothing organic can be detected, and when no cause, such as tea- 
drinking, is discoverable. The children are of a highly neurotic temper- 
ament, and are usually much influenced by exciting surroundings in their 
homes. 

A boy, ten years old, was subject to fits of great excitement brought on by the 
most trivial causes, such as preparing to go to school or to take a journey. For some 
hours before the proper time for starting came he was apt to grow more and more agi- 
tated. He would then often be seized with violent palpitation lasting for several hours 
and forcing him to lie perfectly still on his back. At these times his skin was cool and 
pale, and his pulse weak and irregular. Nothing abnormal was detected on an exam- 
ination of the heart or any other organ. The attacks lasted until he was twelve years 
old, and have never occurred since. 

REFLEX SYMPTOMS OF THE STOMACH. 

There are a number of reflex conditions connected with the stomach 
arising from different causes but represented by the same symptom, 
vomiting. Instances of this condition are those cases of vomiting which 
arise from irritation of the larynx and pharynx and which are cured by 
local applications made to these parts. 

REFLEX SYMPTOMS OF THE BLADDER. 
Reflex spasm of the bladder occurs very frequently in young children, 
and this condition has been described under enuresis, page 871. 

REFLEX SYMPTOMS OF THE VAGINA. 

There is almost always a direct cause to be found for the reflex 

nervous symptoms which arise from vaginal irritation. One of the most 

common causes is the oxyuris vermicularis, which at times gives rise to 

extreme and severe symptoms when it has migrated from the rectum. In 



DISEASES OF THE NERVOUS SYSTEM. 949 

addition to the local irritation, which causes the child great uneasiness, so 
that it cannot sit still and is continually moving its legs about, its tem- 
perament may be much affected. A child with this trouble is apt to be 
very fretful, to have violent outbursts of temper, to lose its appetite, and 
to grow thin. 

A little girl, five years old, had the most extreme vaginal irritation. When I saw 
her she had been affected for several months and was in a very weak condition. At 
times the irritation seemed to be more than she could bear, so that she would lose all 
control of herself, would throw herself on the floor, and would have violent spasmodic 
contractions of the legs. Her sleep was much interfered with, and her whole appear- 
ance was that of a child suffering from some serious disease. An examination showed 
that the oxyuris vermicularis was the cause of the vaginal irritation, and after a few 
days' treatment directed to the expulsion of the parasite the child ceased to have any 
irritation and subsequently recovered entirely. 

REFLEX SYMPTOMS OF THE RECTUM. 
In certain cases reflex symptoms of a most exaggerated type are 
localized in the rectum. The following cases are illustrative ; 

A girl, four years old, had always been remarkably strong and robust, and had 
never had any especial local trouble with the bladder or the rectum. She was, how- 
ever, of an excessively nervous temperament, and was surrounded by exciting in- 
fluences in her home. She began to have spasmodic contractions of the sphincter ani. 
When she attempted to have a movement of the bowels it frightened her, and she 
would clutch at any piece of furniture which happened to be near her and try not to 
have the movement. She would scream and cry out as if she were in much pain. An 
examination under ether showed nothing abnormal in the rectum or sphincter, such as 
from pressure or from lesions, and the condition was apparently simply that of spasm. 
She was treated by the daily dilatation of the sphincter ani with bougies, the size 
being increased gradually. This was followed by marked improvement, and the 
rectal spasm passed away. 

Although the rectal spasm did not return in this case, yet in its place the child 
began to have incontinence of urine. 

Another child, eight years old, for a whole year was affected by intense irritation 
in the region of the anus, which prevented her from sitting down for any length of 
time and kept her in a continual state of irritability. Nothing could be detected 
during this period which caused these symptoms. No trace of intestinal parasites 
could be found, and nothing abnormal, either at the anal orifice or in connection with 
the bowels, was seen, the skin around the anus being in a perfectly normal condition. 
The child was treated with bromide of potassium for several weeks, and recovered en- 
tirely. 

CEREBRAL ABSCESS. 

Cerebral abscess is a localized purulent encephalitis. It is probably 
always secondary to suppurative disease elsewhere. It may arise from a 
suppurative condition of the scalp, but its most common source is some 
purulent disease of the ear or its surroundings. It is also found as a 
sequel to traumatism of various kinds resulting in suppuration and in 
general pyaemia, and it may follow direct traumatic injury to the brain. 
Cerebral abscess is usually single, except when it is produced by pyaemia. 



950 PEDIATRICS. 

The abscess may occur in any part of the brain. Cerebellar abscess is 
not uncommon. 

Symptoms. — A cerebral abscess may exist for a considerable time 
without producing any symptoms which can be recognized during life. 
In cases in which suppurative disease of the ear exists, a cerebral abscess 
may be suspected when, in addition to the temperature, which would 
naturally be raised from this process, the child's general condition be- 
comes worse without any apparent cause, and when indefinite symptoms, 
such as mental dulness and irritability, arise. The temperature and 
marked leucocytosis may also suggest the presence of imprisoned pus, 
and the probability of cerebral disease, in -cases where the pus cannot be 
found elsewhere. Cerebral abscess may, however, exist for a consider- 
able period without rise of temperature, and even with a subnormal 
temperature. It is apt to be slow in its progress and to cause general 
constitutional rather than local symptoms. Local symptoms produced by 
the presence of cerebral abscess are rare. When present, however, they 
are represented by headache, vertigo, mental dulness, vomiting, and con- 
vulsions, and are followed later by coma. When the abscess bursts into 
the ventricles, symptoms of sudden collapse appear, and death rapidly 
follows. Tremor and convulsions may occur in cases of cerebral abscess, 
but neither of them should be considered as in any way symptomatic of this 
condition. 

Prognosis. — The prognosis is very unfavorable unless the disease can 
be reached surgically. 

Treatment. — The treatment should be operative if the abscess can be 
localized. 

CEREBRAL, PARALYSIS (Infantile Cerebral Palsies). 

In using the term cerebral paralysis it must be understood that it is 
not intended to describe every disease of intra-cranial origin from which 
a paralysis may result. We may have a resulting paralysis from many 
intra-cranial lesions, such as hydrocephalus, cerebral abscess, cerebral 
tumors, and other causes. These conditions are not included in the class 
of cases designated as cerebral paralysis or infantile cerebral palsies, which 
are motor disturbances arising from certain cerebral lesions, occurring in 
intra-uterine life, during labor or after birth in the first three or four 
years. 

There is much concerning the definite pathology of this class of cases 
which is still undetermined, so that they will be more clearly understood 
if discussed as a group and their prominent features compared with each 
other. This is all the more necessary as the clinical manifestations of 
all of them are practically the same, and are represented by a spastic 
paralysis involving one or more extremities in the form of a hemiplegia, 
a diplegia, or a paraplegia. Monoplegias are rare in comparison with the 
other forms. Any one of these forms may be accompanied by contrac- 



DISEASES OF THE NERVOUS SYSTEM. 951 

tures, choreiform movements, mental impairment, epilepsy, and a number 
of like nervous symptoms usually spoken of as post-paralytic. 

In 225 cases analyzed by Peterson and Sachs, right hemiplegia oc- 
curred in 81 cases, left hemiplegia in 75, diplegia in 39, and paraplegia 
in 30. 

Etiology. — The cause of cerebral paralysis occurring in intra-uterine 
life has not been definitely determined, and our knowledge concerning 
this class of cases is very vague. It has, however, been found that 
instances not infrequently arise in which there is an hereditary history of 
epilepsy, insanity, or marked neuroses. Traumatism, severe illnesses, and 
fright in the mother are accepted as other possible causes. According to 
Sachs, syphilis does not play the important part in the etiology of intra- 
uterine palsies which has been given to it by some authors. 

The cerebral paralysis, which is the result of conditions occurring 
during labor (birth-palsies), may arise from asphyxia in tedious and pro- 
longed deliveries, which, according to Sachs, are more disastrous than the 
accidents which at times occur when the forceps are used. 

Certain etiological factors are well recognized as causes of the palsies 
which occur after birth in the early years of life. These are traumatic 
injury to the skull, fright, the acute infectious diseases, such as measles, 
scarlet fever, typhoid fever, variola, pneumonia, and cerebro-spinal menin- 
gitis. It has also followed acute tonsillitis, severe cases of gastro-enteric 
disease, pertussis, and, in certain instances, violent convulsions, though in 
most cases of the latter condition the convulsions are probably caused 
by, rather than causative of, the lesions producing the paralysis. 

In some cases the disease arises in apparently healthy children and 
without assignable cause. 

Pathology. — In the intra-uterine cases the lesions, according to Sachs, 
are represented by large cerebral defects (porencephaly), and also by a 
condition designated " agenesis corticalis" in which there is a defective 
development of the cellular elements of the cortical and particularly of 
the pyramidal cells, which is not restricted to any one part of the brain, 
but involves all parts of the hemispheres about equally. This condition 
is met with in the family form of idiocy. 

In the cases which occur during labor, birth-palsies, the primary lesion 
is usually a meningeal hemorrhage (rarely intra-cerebral), and, as shown 
by McNutt, more or less diffuse over both hemispheres. 

In the cases which occur after birth, extra-uterine palsies, as well as in 
the intra-uterine and birth-palsies, a distinction must be made between 
the primary lesions and the terminal conditions. 

In a series of 78 autopsies in infantile hemiplegia analyzed by Peter- 
son and Sachs, there were found as primary lesions, hemorrhage 23, 
embolism 7, thrombosis 5, and tubercle 1 ; while as terminal lesions 
there were atrophy, sclerosis, and cysts 40, and porencephalus 2. Por- 
encephalus denotes a pathological loss of substance, forming cavities or 



952 PEDIATRICS. 

cysts running from the cortex of the brain towards the centre, affecting 
the motor region and being either unilateral or bilateral. Sclerosis con- 
sists of a shrinking and hardening of the cerebral tissues, usually more or 
less strictly localized. 

Although the primary lesions of all forms of the infantile cerebral 
palsies may be caused by embolism or thrombosis, yet these etiological 
factors are rare in comparison with hemorrhage, which is the most com- 
mon cause of the primary acute symptoms. This hemorrhage is more 
apt to be meningeal than cerebral and is usually in the subarachnoid 
space, thus differing from cerebral hemorrhage in the adult, which occurs 
more frequently in the region of the internal capsule. 

Thrombosis may be a cause where changes have taken place in the 
cerebral arteries due to hereditary syphilis, and embolism may be the 
cause in such predisposing affections as valvular cardiac disease. 

The pathology, therefore, of the condition as a whole is a lesion of the 
motor tract followed by atrophy and retarded development of the part 
affected, and a descending degeneration of the pyramidal tracts and 
lateral columns of the cord. It is also possible that the primary cause of 
the disease may be a defective development of the nervous centres. 

Symptoms. — If the lesion has been of intra-uterine origin, we may get 
only the later manifestations, just as we do in congenital syphilis. The 
paralysis in this class of cases is usually diplegic or paraplegic, and mental 
enfeeblement, amounting often to idiocy, is common. When the paraly- 
sis is due to defective cortical development the muscles may be flaccid 
instead of the characteristic spastic condition of the other forms of cere- 
bral paralysis. If the lesion has occurred at the time of delivery, the 
primary symptoms are often masked, and the resulting symptoms of the 
more advanced pathological condition are noticed later. 

The diagnostic early symptoms are paralysis, convulsions, rigidity, 
and stupor ; asphyxia and irregular respirations are common symptoms. 
The symptoms vary with the extent and locality of the lesion. There 
may be bulging of the fontanelle, changes in the pupils, and oscillation of 
the eyeballs. 

When the disease develops in extra-uterine life it is usually acute in 
its character and is marked by more or less fever, convulsions, and 
stupor. These early symptoms are merely those of a general nervous 
explosion following an irritation of the nervous motor centres. They 
may be the first manifestations of a disease of any kind, or they may 
occur in the course of one of the diseases of which I have spoken under 
etiology. If they happen to occur at night and are of short duration, 
they may be entirely overlooked, and the later symptoms of a cerebral 
lesion may be the first ones to manifest themselves. The child may die 
from the severity of these initial lesions before the later symptoms of 
paralysis have developed by which we can diagnosticate the disease. 
Screaming, vomiting, and delirium may at times usher in the attack. In 



DISEASES OF THE NERVOUS SYSTEM. 953 

the midst of or closely following these primary symptoms come the pro- 
nounced indications of a central nervous lesion, represented by hemi- 
plegia (paralysis of an arm and a leg on the same side), paraplegia 
(paralysis of both legs), or diplegia (paralysis of corresponding parts on 
the two sides of the body), cases of hemiplegia being the most common. 
In rare cases we find only one extremity affected (monoplegia). Hemi- 
plegia is by far the most common form. 

In addition to the paralysis of the limbs, facial paralysis may occur 
either in hemiplegia or in diplegia, and, as a rule, spares the upper part 
of the face, so that -the eyes can be closed and the brows raised, thus 
showing that it is not a peripheral facial paralysis. This form of facial 
paralysis often disappears early. Strabismus is common. 

On examining the paralyzed limb we find a resistance to motion, the 
deep reflexes are exaggerated, and in most cases there is a feeling of 
rigidity on the paralyzed side. A few cases of flaccid paralysis have 
been reported. Sensation, as a rule, is not affected. When the child 
has come out of its stupor and the convulsions have ceased, it may be 
found to be aphasic, but aphasia is not so common as in the cerebral 
lesions of adults. The intelligence is usually impaired, but this depends 
upon the extent and location of the lesion and the period when it occurred. 

The intra-uterine and early infantile cases show the greatest mental 
disturbance. These children are apt to be very irritable, and, when the 
lesion is cortical, epileptiform convulsions are quite common. The mind 
may, however, remain perfectly clear in both the early and late stages of 
the disease, in spite of a marked hemiplegia. The electrical reaction of 
the muscles is normal. In the more advanced stages of cerebral paraly- 
sis additional symptoms begin to appear. The child learns to walk late, 
or, if it has already walked, the gait becomes peculiar. Rigidity fol- 
lowed by contracture of the flexor and adductor muscles occurs. In 
about seventy-five per cent, of the cases of diplegia and paraplegia it 
comes early and develops oftener than in the adult cases. The rigidity 
is increased by manipulation or use of the limb, and disappears during 
sleep. Post-hemiplegic movements follow in a certain number of cases ; 
in others the spastic condition is so pronounced that the patellar tendon 
reflex and the ankle-clonus cannot be obtained. When walking is at- 
tempted, the patient is apt to stand on the toes, the knees knock together, 
and the spastic rigidity of the muscles produces what is called the spastic 
gait, represented in its exaggerated form by the cross-legged progression 
which is largely caused by the rigidity of the adductors of the thigh. 
Pes equmus and pes equino-varus are the most common deformities of 
the foot. When the arm is affected with contractures, the fingers are 
pressed into the palm of the hand, the hand is flexed, and the arm is 
flexed at the elbow and held close to the side. 

The affected limbs are apt to show some disturbance of their circula- 
tion, and some coldness. There are more or less atrophy and shorten- 



954 PEDIATRICS. 

ing of the bone, but to a less degree than in cases of poliomyelitis 
anterior. In a certain number of cases involuntary incoordinate move- 
ments are excited in the paralyzed limbs on voluntary effort (hemiataxia), 
and are usually designated as post-hemiplegic chorea. There may also 
be continuous movements (athetosis) of either a partial or a general 
variety. The sphincters are not affected, whether the case is one of 
hemiplegia or of paraplegia. Epileptiform convulsions may appear quite 
early in cases of cerebral paralysis, but may also be delayed for a number 
of years, so that the possibility of these children becoming epileptic must 
always be considered. 

Diagnosis. — The diagnosis in a marked case of the disease is not diffi- 
cult, but the determination of the exact lesion is often impossible after 
the period of onset has passed and we are left with a resulting paralysis. 
If facial paralysis is present, we can, as a rule, say that the lesion is in 
the brain ; but this rule does not always hold good, as there have been 
very rare cases in which this paralysis was present when the lesion was 
in the cord. 

The symptoms on which we chiefly rely in making our diagnosis of 
cerebral paralysis are (1) the distribution of the paralysis, hemiplegic, 
usually, or paraplegic ; (2) rigidity of the muscles ; (3) increased tendon 
reflex ; (4) comparatively slight wasting ; (5) normal electrical reaction ; 
and (6) mental impairment. Choreic or athetoid unilateral movements 
associated with a slight increase of tendon reflex point towards a previous 
cerebral paralysis. 

From Poliomyelitis Anterior. — The principal disease from which cere- 
bral paralysis is to be distinguished is poliomyelitis anterior. In contra- 
distinction to the chief diagnostic symptoms of cerebral paralysis just 
stated we find in poliomyelitis anterior (1) that the distribution of the 
paralysis is usually monoplegic ; (2) that there is an absence of tendon 
reflex ; (3) that there is an absence of rigidity in the early stages ; (4) 
that there is rapid and marked wasting of the affected limbs ; (5) that the 
reaction of degeneration is present ; and (6) that there is no mental im- 
pairment. 

From Idiocy. — In certain cases also a difficulty may arise in correctly 
understanding the relationship between cerebral paralysis and idiocy. 
The cerebral lesion is in many cases probably the same, but, according to 
its extent and location, we may have either (1) a cerebral paralysis alone ; 
(2) a cerebral paralysis accompanied by mental impairment or idiocy ; 
or (3) idiocy without cerebral paralysis. There is a certain class of low- 
grade idiots in which some impairment of motion exists, apparently due 
to a mental inability to co-ordinate the muscles of the limbs properly. 
This may sometimes be accompanied by a diminution of sensation, which 
seems to be due to a want of perception in the higher nervous centres 
rather than to any actual lesion of the sensory tract. When the idiot's 
attention can be kept centred on the limb, the actual sensation does not 



DISEASES OF THE NERVOUS SYSTEM. 955 

seem to be much impaired. The differential diagnosis of this condition 
in idiots from cerebral paralysis is easily made, for it exists only in those 
cases of idiots in whom the mental development is much impaired, and 
it is not, as a rule, accompanied by true paralysis, as there is no weakness, 
but simply incoordination ; in these cases also the tendon reflexes are, as 
a rule, not increased. 

From Caries of the Spine. — Cerebral paralysis can be diagnosticated from 
the paralysis which occurs in connection with caries of the spine, princi- 
pally by the presence of cerebral symptoms in one case and the promi- 
nence of the spinal vertebrae and the rigidity of the spine in the other. 

From Syringomyelia. — Rare cases of syringomyelia may be mistaken 
for cerebral paralysis. The points of differential diagnosis in these cases 
are that in syringomyelia, although the weakness of the limbs may be so 
extensive as closely to simulate paralysis, yet the diminution of thermic 
sensation easily distinguishes it from the normal sensation which is present 
in cerebral paralysis in cases where the test for sensation can be em- 
ployed. Syringomyelia, however, is so rare in children that the diagnosis 
need not be dwelt upon. 

Prognosis. — In the intra-uterine forms of cerebral paralysis a large 
number of infants die at varying periods during the early months of life, 
so that for some weeks, at least, a prognosis as to life cannot be given. 
Quite a large number, besides developing epilepsy, also show the condi- 
tion of idiocy. 

A severe lesion may be inferred if convulsions occur in the early weeks 
and if apathy continues in the intervals between the convulsions. If after 
a few weeks or months the convulsions are markedly diminished, and if 
the infant begins to use its legs and to take notice of things, a more favor- 
able prognosis can be given. So long as contractures do not develop a 
fair use of the extremities may be acquired. Sachs states that in the 
intra-uterine cases diplegia and paraplegia are more apt to be associated 
with cerebral deficiency and epilepsy than is hemiplegia. 

In the acute extra-uterine cases the prognosis for life in cerebral paraly- 
sis is soon determined in the early days of the attack, and depends on the 
location and extent of the cerebral lesion, but the uncertainty in some 
cases may last for a number of weeks. On account of the usual menin- 
geal form of the hemorrhage it is less likely to prove fatal in infants than 
in adults. Entire recovery is rare. In hemiplegia the paralysis will prob- 
ably improve. The spastic rigidity usually goes on to decided contracture. 
In some cases no mental change is apparent, in others the mental devel- 
opment is merely retarded, and the child learns to talk some years later 
than is normal. In a large number of cases, however, the mind is much 
enfeebled. The occurrence of epilepsy as a result of cerebral paralysis 
is so common that it should be especially mentioned in this connection, 
as it makes the prognosis much more serious both as to the degree to 
which the mental impairment may attain and as to the life of the patient. 



956 PEDIATRICS. 

According to Gaudard, Osier, Wallenberg, and Sachs, the development 
of convulsions after an infantile apoplectic attack makes it probable that 
chronic epilepsy will result, and the prognosis becomes much more grave. 
Statistics show that epilepsy follows the hemiplegic cases rather more fre- 
quently than it does the diplegic and paraplegic, and that it occurs in 
about half the cases of hemiplegia. If after a few weeks there is improve- 
ment, the prognosis is good ; if, on the contrary, there is no improvement 
for months, it is bad. In some cases, however, after improving for even 
a year, convulsions may appear and epilepsy develop. Except in very 
rare cases, the children can eventually be taught to walk. In many in- 
stances, although during infancy there is complete helplessness, later the 
condition is much improved, and sometimes considerable activity results. 

Treatment. — In the intra-uterine cases, as it is the later manifestations 
of the disease which are met with, the treatment should be the same as 
is indicated in the late treatment of the birth-palsies and of the extra- 
uterine cases. In acute cases the infant should be kept perfectly quiet T 
and, if unconscious and unable to nurse, the mother's milk or a carefully 
modified milk should be given by means of a dropper. If convulsions 
appear, small doses of the bromides, 0.18 to 0.48 gramme (3 to 8 grains), 
or chloral, 0.06 to 0.3 gramme (1 to 5 grains), and inhalations of ether are 
indicated, and in protracted convulsions minute doses of morphia, 0.0006 
gramme (0.01 grain). The treatment of the muscular contractures fol- 
lowing cerebral paralysis by tenotomy or apparatus is of the greatest 
importance, and should be. referred to the orthopaedic surgeon as soon as 
possible. 

Although the application of ice to the back of the neck is recom- 
mended when a cerebral hemorrhage is suspected, yet in young infants 
this procedure should be used with great caution, as cold is so apt to 
reduce their vitality. 

The following case of cerebral paralysis had left spastic hemiplegia : 

The boy was six years old. The delivery was terminated with forceps, but the 
labor was not a severe one, and he was healthy at birth. He developed normally for 
two years, and walked when he was eighteen months old. He had convulsions in his 
third year, and these convulsions occurred again when he was four years old. They 
were followed by paralysis. He could not use his left hand well, and the grasp of the 
left hand was less strong than that of the right. The triceps reflex was exaggerated on 
both sides. The left foot could with difficulty be flexed dorsally. The right knee- 
jerk was normal, the left increased. He had flat-foot, and walked with his left foot 
inwardly rotated. He was otherwise well and strong. 

The following case represents hemiplegia of traumatic origin, probably 
hemorrhage : 

A girl, four years and nine months old, was brought to the hospital with a history of 
having fallen from the roof of a three-story building upon a brick sidewalk. She was un- 
conscious. She vomited slightly, and she was found to have an ecchmyosis on the left side 
of her head. Her pupils were equal and reacted to light. Her respirations were rapid ; 



DISEASES OF THE NERVOUS SYSTEM. 



957 



the extremities were cold. She moved all her limbs vigorously. Some clotted blood 
was found in and about the nostrils. The temperature was 36.3° C. (97.4° F.) ; the 
pulse was 90, and the respirations were 26. She ground her teeth and cried out in 
the night. The muscles of the left arm and leg moved actively. 

During the next four days she remained unconscious. Involuntary micturition, 
inequality of the pupils, the right pupil not reacting to light, irregular pulse, and 
slight opisthotonos developed as new symptoms. 

On the seventh day she appeared brighter, and followed objects with her eyes. Her 
pulse was irregular, from 80 to 90. 

Two days later she made voluntary movements, such as to push objects away from 
her, and gave evidence that she understood what was said to her. From that time she 
slowly improved. 



Fig. 191. 

■ *:«■ 




isL 'J §fit 



Fig. 192. 




Cerebral paralysis. Spastic paraplegia. Cross- 
legged progression. Male, 5% years old. 



Cerebral paralysis. Diplegia. The left 
extremities affected more than the right. 
Female, 5 years old. 



On the twenty-ninth day from the time when the accident occurred she could 
walk, though with difficulty, as the right leg was very unsteady. One week later she 
was discharged from the hospital. She could then use the right arm fairly well, but 
still walked with some difficulty on account of the weakness of the right leg. Her 
articulation was labored, and her pupils were still unequal. 



958 PEDIATRICS. 

The following case (Fig. 191) represents a boy, five and a half years 
old, with spastic paraplegia resulting from a cerebral paralysis and showing 
cross-legged progression • 

The cerebral lesion occurred when he was an infant. Nothing abnormal was 
noticed about him until he was fifteen months old, when it was observed that he could 
not walk. He had more or less mental impairment, nystagmus, stiffness of the ad- 
ductor and flexor muscles, and paralysis of the extensors of the lower extremities. 
The knee-jerks were much increased, and there was slight ankle-clonus. He walked 
in the characteristic manner called cross-legged progression. 

The following case (Fig. 192) represents a girl, five years old, affected 
with diplegia resulting from a cerebral paralysis : 

She had a good family history. The labor was easy, and was not instrumental. 
She developed well and was healthy until she was ten months old, when it was noticed 
that she did not move her arms as she ought to, that she did not use her left arm at 
all, and that the left leg was not used as well as the right. This condition persisted. 

She had strabismus. She could not hold' her head up straight. She could not sit 
up alone or stand. Her head was small and narrow, and had a long antero-posterior 
diameter. The reflexes were increased. The power of her left arm was much im- 
paired, and there was some contraction of the fingers and elbow of a spastic character. 
She did not move her left leg well. Sensation was dulled alike in both legs. Her face 
had an idiotic expression, she was poorly developed mentally, and she could not talk. 

She showed the form of spastic cerebral paralysis which is called diplegia, the left 
extremities being more affected than the right. The face was not involved in this case. 

The prognosis of a case like this is unfavorable so far as recovery is concerned, on 
account of the great mental impairment. Operative treatment is, however, indicated, 
as at times improvement results in even decidedly idiotic cases. 

MYELITIS. 

The term myelitis denotes an inflammation of the spinal cord, whether 
of the gray or of the white matter. Acute myelitis has been used to 
designate an acute diffuse inflammation of both the gray and the white 
matter of the cord of non-traumatic origin, and is an affection almost 
unknown in children. 

The term meningo-myelitis is used to denote an inflammation of the 
meninges and of the spinal cord. 

Acute myelitis, meningo-myelitis, and hemorrhage into the cord are 
extremely rare in early life. 

INFANTILE SPINAL PARALYSIS ( Poliomyelitis Anterior Acuta). 

Infantile spinal paralysis is the most frequent and therefore the most 
important disease which affects the spinal cord, with a resulting paralysis, 
in infancy and early childhood. It occurs most commonly in the first 
three years of life. It is rare in the first six months of life. It may 
occur in later childhood, and very rarely in adults. It is met with more 
commonly than cerebral paralysis. It is represented clinically by a motor 
paralysis rapidly leading to atrophy of the muscles affected. 



DISEASES OF THE NERVOUS SYSTEM. 959 

Etiology. — The disease may be primary, in which case it is without 
any known cause ; or it may be apparently secondary to other diseases, 
such as the acute exanthemata and erysipelas. Traumatism appears occa- 
sionally to give rise to the condition. Most of the cases occur during the 
summer months, and at night rather than during the day. It attacks 
healthy children as well as unhealthy. It is not hereditary. It may 
occur in epidemics, and is therefore supposed to be infectious in its origin, 
but no specific organism has been discovered. 

Pathology. — The pathology of poliomyelitis is still not definitely deter- 
mined. It is at present believed that the gray matter and its ganglion-cells 
may be involved throughout the entire length of the cord, the process 
being an interstitial inflammation with secondary changes of a degenera- 
tive character in the ganglion-cells. The cervical and lumbar enlarge- 
ments are most frequently affected. 

Goldsheider's investigations show that irritation is present in the walls 
of the blood-vessels, Avhich leads to their dilatation and to a proliferation 
of their endothelial elements ; the morbid process then extends to the 
neuroglia and produces a proliferation of its cells. He believes that the 
changes in the ganglion-cells and in the nerve-fibres are secondary and 
due to disease of the blood-vessels. Secondary changes also take place 
in the columns of Clarke, which disappear, and the anterior nerve-roots 
become smaller than those on the opposite side. 

This condition may be confined to the anterior cornua, but in some 
cases it may involve the spinal meninges. So few post-mortem examina- 
tions of the early lesions connected with this disease have been made 
that we are dependent for our knowledge of it mostly on cases which 
have been examined a number of months or years after the production of 
the initial lesion. These later pathological conditions are, however, quite 
characteristic. The circumference of the limb grows small in comparison 
with that of the opposite one, being the result of an active muscular wasting 
and of retarded growth. The bones of the affected limbs are often shorter 
than those of the other side, sometimes even to the extent of several 
inches. In certain cases, however, the lengths of the bones seem to be 
but little affected, although the atrophy of the muscles may be very 
marked. The anterior cornua of the region affected, which is usually in 
either the cervical or the lumbar enlargement, are found to be greatly 
atrophied and many of the large motor cells to have been destroyed. 
The affected half of the cord may be considerably smaller than the other, 
and the anterior lateral column may show slight sclerotic changes, chiefly 
in the pyramidal tract. Accompanying this condition the corresponding 
anterior nerve-roots are found to be atrophied, and the muscles connected 
with the region of the cord which is affected atrophy and gradually un- 
dergo a fatty and sclerotic change. The fibres are much diminished in 
size, many have disappeared altogether, and the normal fibres are at times 
replaced by adipose tissue. 



960 PEDIATRICS. 

Symptoms. — The onset of the disease in the great majority of cases is 
acute.- Its course is chronic. In the acute form the onset may be pre- 
ceded for some days by fever and restlessness, but it is apt to appear sud- 
denly with convulsions which, as a rule, are of a milder type than those 
which occur in cerebral paralysis, are general, and at times absent. The 
subacute variety of poliomyelitis anterior does not differ from the acute 
cases in any way in its symptoms, prognosis, diagnosis, and treatment. 

Following the acute onset there are at times unconsciousness, lasting 
sometimes for a number of days, vomiting, general nervous disturbance 
of the bladder and intestines, and a variety of symptoms of nervous 
irritability which may represent the prodromata of a number of diseases. 
The vomiting, when it occurs, accompanies the initial fever, resembles, 
according to Sachs, the cerebral type, and is not connected with gastric 
disturbance. Coma may be present, but is rarer than convulsions, and is 
not usually profound. The temperature is seldom very high, 38.3° to 
38.7° C. (101° to 102° F.) ; it may, however, in certain cases be higher. 
At times there are no prodromata, but the paralysis is noticed in the morn- 
ing after a night's rest, although on the evening before the child was 
seemingly perfectly well. The severity and length of the prodromal 
symptoms are no indications of the gravity of the lesion or of the prog- 
nosis as to recovery. Pain in the paralyzed limb is not an uncommon 
symptom, but occurs only very early in the disease. The temperature of 
the limb is lowered, there is vascular sluggishness, and the limb has a 
bluish, flaccid, undeveloped look. The disease is primarily a motor dis- 
turbance, sensation remaining intact. Cerebral symptoms, if present, 
pass off rapidly with the appearance of the paralysis. The paralysis is 
usually apt to affect more than one limb in the beginning, but, as a rule, 
soon becomes monoplegic. The leg is more frequently affected than the 
arm. Paraplegia in the beginning is not uncommon, and all forms of 
paralysis may occur. There may also be diplegia, crossed paralysis, and 
paralysis of the muscles of the back and abdomen. Hemiplegia, so com- 
mon and almost characteristic of cerebral paralysis, may be present, but 
is rare in poliomyelitis anterior. The muscles most frequently affected are 
the extensors, adductors, and supinators. The distribution of the paralysis 
is usually in groups of muscles. The respiratory muscles may be affected, 
although rarely. Facial paralysis is so rare that it can almost be said never 
to occur in uncomplicated poliomyelitis. When the prodromal symptoms 
have passed off, as they usually do very quickly, the functions of the body 
are carried on as usual, and the general growth and mental activity are 
unimpaired. The tendon reflexes disappear in the affected limbs when 
all the muscles are severely affected. When the paralysis has reached its 
height, which is usually in a few hours or days, it remains stationary for 
perhaps from three to six weeks, and then gradual improvement begins, 
and goes on in certain groups of the paralyzed muscles for six or eight 
months, leaving other groups paralyzed. These groups again at times 



DISEASES OF THE NERVOUS SYSTEM. 961 

recover entirely or remain disorganized, and thus lead later to contractures 
and deformities. When contractures occur they appear later than do those 
of cerebral origin. 

When paralysis affects wholly or chiefly the gastrocnemii and posterior 
tibial muscles, the other groups act predominantly, causing dorsal flexion 
of the foot, so that the child walks on its heel. This condition is termed 
talipes calcaneus. When, on the other hand, the tibialis anticus and ante- 
rior muscles of the leg are most affected, the deformity of talipes equinus 
occurs ; and if the peroneal muscles remain unaffected, there is valgus, 
while if they are affected with the anterior group, talipes equino-varus 
occurs. Dislocation of the hip may occur in rare cases of complete pa- 
ralysis of the leg. Severe cases may show complete flaccidity, and not 
infrequently the ligaments about the joints are so Aveakened that the joints 
become too movable, and the condition called flail-joint results. This con- 
dition may be present at the hip, knee, or ankle, and sometimes at the 
shoulder or wrist. Marked atrophy appears in a few weeks. Muscular 
atrophy, rapid and extreme, is the rule in poliomyelitis anterior, and 
begins a few weeks after the appearance of the paralysis. Shortening of 
the bones from arrest of growth may also appear. The surface tempera- 
ture of the affected limb is lowered, the limb feels cold, relaxed, and life- 
less, and the circulation is generally sluggish. Spasmodic movements, 
except the primary convulsions, are absent. 

In rare cases improvement begins immediately after the attack, and 
goes on to complete recovery (temporary spinal paralysis). 

In the epidemic form the fever is apt to be high, the distribution of the 
paralyses extensive, and in a series of ten cases examined by Brackett 
the sphincters were at times involved, and in the severe cases prolonged 
hyperesthesia occurred. 

Diagnosis. — In the stage of onset, and until paralysis has appeared, the 
diagnosis must be held in abeyance. The salient points by which a diag- 
nosis can usually be made are (1) sudden paralysis ; (2) loss of tendon 
reflex ; (3) rapid atrophy ; (4) cold, flaccid limbs ; (5) absence of impair- 
ment of sensation ; (6) presence of the reaction of degeneration and a 
diminished reaction to the faradic current. 

It is always difficult to diagnosticate poliomyelitis in the initial stage of 
the disease. At that time pain and sensitiveness of the affected limb may 
be present, and may lead us to suspect that the disease is rheumatism. 
The convulsions and unconsciousness which may appear at this stage are 
so often present in other diseases that they are not of much aid in making 
the diagnosis of poliomyelitis anterior. 

The most reliable test at our command for making the diagnosis of 
poliomyelitis anterior is the electrical reaction. The normal muscles react 
to both the faradic and the galvanic current. In applying the galvanic 
current a quick muscular contraction is noticed both on the opening and 
on the closing of the negative (cathodal) and of the positive (anodal) pole, 

61 



962 



PEDIATRICS. 



but is greater when the cathodal pole is closed. When the galvanic cur- 
rent is applied to the muscles affected by poliomyelitis anterior, the con- 
tractions continue, but are slower and less sharp, and the reverse of what 
takes place in normal muscles occurs. Thus, the anodal closure causes 
a contraction equal to or greater than that caused by the cathodal closure 
(reaction of degeneration). As the muscles recover there is first a return 
to the normal galvanic reaction and later to their normal faradic excita- 
bility. The diagnosis in young children, however, by means of the gal- 
vanic current is practically useless except in the hands of an expert. 
The faradic excitability begins to diminish within a few days after the 
onset of the paralysis, and disappears entirely from those muscles which 
are severely affected. 

From Cerebral Paralysis.— Poliomyelitis anterior is most apt to be mis- 
taken for cerebral paralysis, and can be best differentiated from that dis- 
ease by means of the symptoms which have been described. 

TABLE 76. 



. 


Cerebral Paralysis. 


Poliomyelitis Anterior. 


Motor disturbance 


Paralysis. Most common form 


Paralysis. Most common form 




hemiplegia. 


monoplegia. 




Spastic rigidity. 


Flaccid. 




Spastic gait. 


G-roups of muscles in a limb 




All the muscles of a limb af- 


affected, usually the exten- 




fected. 


sors. 


Contractures 


Of all the muscles, especially 
the flexors and adductors. 


Of the flexors in the calf. 


Spasmodic movements . . . 


Athetosis. 


Absent. 




Post-paralytic chorea. 


Convulsions may occur at the 




Epileptiform convulsions. 


onset of the disease. 


Sensation 


Unaffected. 
Arrest of growth. 


Unaffected. 


Nutrition 


Tendency to extreme atrophy 






coming on early in the para- 






lyzed limb. 


Electrical reaction. ...... 


Normal. 


Reaction of degeneration. 


Tendon reflex 


Exaggerated on the paralyzed 

side. 
Liable to be impaired. 


Absent. 


Speech 


Unimpaired. 


Intelligence 


Often impaired. 


Normal. 



From Multiple Neuritis. — The principal points by which multiple neu- 
ritis is to be distinguished from poliomyelitis anterior are (a) the sym- 
metrical affection of the limbs in the former and tenderness over the 
nerve-trunks ; (b) the atrophy in multiple neuritis is not so severe as in 
cases of poliomyelitis anterior ; (c) the course of the disease is different, 
cases of multiple neuritis almost invariably recovering, while severe cases 
of poliomyelitis do not recover. 

From Progressive Central and Progressive Neural Muscular Atrophies. 
— The diagnosis of these conditions will be found on pages 991 and 992. 

From Pseudo-Hypertrophic Muscular Dystrophies. — Pseudo-hypertrophic 
muscular paralysis in its early stage is not likely to be mistaken for polio- 



DISEASES OF THE NERVOUS SYSTEM. 963 

myelitis, but in the later stages of this disease, in which atrophy may 
occur, it may be necessary to make a differential diagnosis. This will be 
described on page 994. 

From Rhachitis. — In certain cases of rhachitis the power of using the 
legs is so much affected that the mistake is quite commonly made of sup- 
posing that these children are affected by poliomyelitis anterior. The 
condition in rhachitic children is one of weakness and not of paralysis, 
and can be distinguished by the normal electrical reaction of the muscles, 
by the presence of normal reflexes, and by the lack of pronounced atrophy. 

From the Pseudo-Paralysis of Scorbutus. — The pseudo-paralysis which 
is commonly seen in cases of scorbutus is often mistaken for some organic 
disease of the central nervous system, with its resulting paralysis. The 
differential diagnosis from poliomyelitis anterior, however, is not diffi- 
cult to make, for the involvement of other joints in addition to those of 
the legs, the presence of pain and tenderness to such a degree that the 
child cries whenever the limbs are touched, and the normal temperature 
of the skin clearly distinguish this condition from poliomyelitis, in which 
disease normal sensation, freedom from pain, and a cold feeling of the 
limb affected are found. 

Prognosis. — So far as a fatal issue is concerned, the prognosis is very 
favorable. If death occurs, it usually takes place at the end of one or 
two weeks, and is the result of interference with respiration, which may 
be caused when the paralysis is extensive. When in the initial stage of 
the attack cerebral symptoms are prominent and continue for some time, 
the prognosis is grave. The prognosis is not so good in the epidemic 
form, which is much more severe in its manifestations. 

A second attack of the disease is very rare, and when it occurs it 
usually comes a few days after the original attack, and manifests itself by 
an increase of the existing paralysis. The paralysis, as a rule, will not. 
increase when it has been stationary for. twenty-four hours. The tendency 
of poliomyelitis is for a time to improve. Some of the limbs affected 
recover in the first few days, but if the paralysis persists longer perfect 
recovery is rare. When there is no improvement after six or eight 
months the probability is that entire recovery will never take place, al- 
though under proper treatment slight improvement may go on for years. 

We must remember that, even when untreated, a case of poliomyelitis 
is very apt to improve for one or two months quite rapidly, then slowly 
for two or three months, and after a stationary period, contractions, 
looseness of the joints, and malpositions may begin to be evident and 
may increase indefinitely. 

When proper treatment is carried out, the prognosis is much more 
favorable, and the period of possible improvement can be extended for 
some years. According to Bradford and Lovett, there is certainly no 
leg, however wasted and contracted, that is not amenable to some 
improvement by operative or mechanical treatment. 



964 PEDIATRICS. 

Treatment. — The treatment of poliomyelitis by means of drugs has 
produced such unsatisfactory results that it may be said to be useless. 
At the onset of the attack the bowels should be freely moved, and con- 
vulsions, if present, should be treated symptomatically, as described on 
page 914. 

Although we know of no rational means of treating the primary 
lesion of poliomyelitis anterior, we know that the results of this lesion, 
as shown by paralysis of the muscles, are such that the paralysis should 
be treated at once. The indication is to combat the rapid atrophy which 
is part of the disease, and to prevent its increase and its later results 
from proceeding to a degree which would interfere with subsequent 
repair. To accomplish this, the affected limb should be supported in a 
normal position and carefully guarded against the stretching of joints, 
ligaments, and muscles. In addition to this, after an interval of two 
weeks, gentle massage and the galvanic current applied five or ten min- 
utes at a time at least four or five times a week are indicated to keep the 
affected muscles in the best possible condition and to combat the atrophy 
which to a greater or less degree occurs. The regular application of heat 
is also found to be useful where the limb is cold. The muscles are much 
less likely to contract and deformities to result in properly supported 
limbs. 

The later manifestations of club-foot and other deformities should be 
dealt with by the orthopaedic surgeon. Tenotomy and the transplanta- 
tion of tendons are of benefit in many severe cases. 

The following case and Fig. 193 represent poliomyelitis in a girl nine 
years old : 

She was perfectly well up to the time of an attack, which came on suddenly and 
without known cause. She was said to have fallen while she was playing, but no 
injury of the leg could be detected, although she was carefully examined under ether. 
The exact date of the attack was not known, but it was not recent. Her general 
health was reported to have been very good, and she seemed to be bright mentally. 
She was well developed, and had a good color. Nothing abnormal had been detected 
on physical examination of the lungs, thorax, abdomen, or other organs. The pulse 
was regular and of good strength. The left leg showed considerable atrophy, being 
4.37 cm. (If inches) smaller than the right in the calf and 2.5 cm. (1 inch) in the 
thigh. The leg was somewhat cyanotic, and was cold to the touch. There was marked 
weakness of the muscles below the knee, especially the extensors of the foot and of 
the toes. When she was lying in bed the movements of the thigh were performed with 
some strength. On walking she rotated the leg outward, so that the foot was at right 
angles with the line of motion, and she dragged the toes. The joints were freely 
movable. Nothing abnormal had been detected in connection with the spine, Avhich 
presented the condition of a movable lateral curvature, due to the shortening of the 
affected leg. As the primary lesion probably occurred some years previously, the prog- 
nosis was bad as to complete recovery or much improvement. 

Fig. 194 represents a girl, two and one-half years old, who had an 
attack of poliomyelitis anterior of the abdominal muscles. 



DISEASES OF THE NERVOUS SYSTEM. 



965 



She had a sister who was said to have had an attack of poliomyelitis anterior when 
she was ten months old. No other history had been obtained about this case, except 
that she was well and strong until this attack, which occurred six weeks previous to the 
time when the picture was taken. The onset of the disease was sudden, and was 



Fig. 193. 



Fig. 194. 




Poliomyelitis anterior 



Poliomyelitis anterior. Abdominal muscles, 
left side. Female, 2% years old. 



accompanied by high fever, followed in three days by complete paralysis of the 
muscles of the upper and lower extremities of the body and of the head. The arms and 
head soon recovered. She was unable to sit up alone, and the abdominal muscles were 
paralyzed to such an extent on the left side that they were flaccid, bulged out, and did 
not react normally. The left leg was perfectly flaccid. The knee-jerks were absent. 
The surface temperature was diminished, and there was atrophy of both legs. Under 
treatment with electricity and massage, complete recovery took place in this case. 



Fig. 195 represents the condition of flail leg following an attack of 
poliomyelitis anterior. 

A boy, six and one-half years old, was apparently healthy at birth, and had never 
had any illness. When he was one year old he was noticed to have some motor dis- 



966 



PEDIATRICS. 



turbance of the left leg. On examination of the leg when he was two and a half 
years old the surface temperature was found to be diminished, the knee-jerk was ab- 
sent, and there was an atrophy of 5 cm. (2 inches) of the thigh and 6.5 cm. (2 J 
inches) of the calf. There was also 3.7 cm. (1J inches) shortening in the leg. The 
child walked with a marked limp of the left leg, and there was the condition of flail- 
joint in his left knee and ankle. This was a typical case of the appearances presented 
in the advanced stages of a severe case of poliomyelitis anterior. 



Fig. 195. 





Poliomyelitis anterior. Flail leg, left 
side. Male, 6% years old. 



Poliomyelitis anterior. Talipes equinus 
on right side. Male, 11% years old. 



The following case represents diplegia caused by poliomyelitis : 



The child, a girl of five years, was well and strong until about her third year, 
when she had an attack of whooping-cough. During this attack she also had some 
other illness, which was characterized by fever and pain in the back. The loss of 
power of her legs dated from this time, and is said to have been gradual. She was 
fairly well developed, and the paralysis had affected both legs and thighs as well as the 
psoas and iliac muscles. There was marked atrophy, and the reflexes were absent. 

The limbs were held apart and were flaccid. If the case had been one of cerebral 
paralysis there would have been in place of this flaccid condition a contraction of the 
adductors of the thigh, which would have been apt to hold the limbs closely together. 



DISEASES OF THE NERVOUS SYSTEM. 967 

Fig. 196 represents a boy, eleven and a half years old, with talipes 
equinus following acute poliomyelitis anterior. 

The anterior portion of the foot was flexed at a sharp angle at the medio-tarsal 
joint. The foot could be easily bent to a right angle, but not beyond. Tense bands 
of plantar fascia could be felt when the foot was straightened out, but it could be 
brought into position by the use of considerable force. The length of the legs was 
equal. There was 1 cm. (about } inch) atrophy in the right calf and 0.6 cm. (| inch) 
of the right thigh. 

This condition of talipes equinus resulted from a contraction of the flexor muscles 
following an attack of infantile paralysis. 

PARALYSIS CAUSED BY CARIES OF THE SPINE. 

In cases of paralysis caused by caries of the spine the lesion is essen- 
tially a compression of the cord : this is usually slow in its progress, and 
is not apparently a true inflammation even in the beginning. The condi- 
tion resulting from compression occurring in the course of caries of the 
spine may be found in any part of the cord. It is most frequently met 
with in disease of the dorsal region, though it may occur in the cervical 
and lumbar regions. In caries of the spine the compression of the cord 
is not often the result of pressure from the vertebrae, but usually is caused 
either by an abscess in the vicinity of the diseased vertebrae, or more 
commonly by a thickening of the meninges. 

Etiology. — When the lesions of the cord are of any considerable 
extent, ascending and descending secondary degenerations follow after a 
time. If the process ceases, it leaves a certain amount of sclerosis of the 
cord at the seat of the disease. This may be very slight, or the cord 
may be considerably reduced in size and yet may transmit normal ner- 
vous impulses. 

Symptoms. — The onset of the disease is sometimes quite sudden, but 
more frequently it is gradual. The symptoms vary according to the part 
of the cord which is affected. 

When the lesion is in the dorsal or the lumbar region the onset is 
represented by numbness and weakness in the legs. This is quickly fol- 
lowed by a paralysis which may become complete in a short time. 

If the lesion is below the level of the sixth dorsal vertebra, the legs 
alone are affected ; if on a level with this point, the abdominal muscles 
are involved. Sensation up to nearly the level of the lesion may be 
diminished, or even lost entirely. In regions above the lumbar enlarge- 
ment the reflex reactions are exaggerated and ankle-clonus soon appears. 

When the disease affects the cervical enlargement, or any portion of 
the cord above, all the extremities are apt to be paralyzed. In severe 
cases there will be retention of urine, with subsequent incontinence. 
The bowels are usually constipated, but incontinence of faeces is some- 
times present. 

In lesions of the lumbar enlargement the knee-jerks will be lost. 



968 PEDIATRICS. 

Trophic changes in the limbs are not marked, but the muscles are some- 
what wasted, and rigidity may develop. Bed-sores are apt to form. The 
reaction of degeneration is not present. 

The characteristic feature of lesions in the dorsal region caused by 
caries of the spine is a paraplegia. 

Diagnosis. — The disease is to be differentiated from poliomyelitis ante- 
rior, in which monoplegia is more common than paraplegia, and in which 
the reflexes are lost and the reaction of degeneration is present. In 
addition to this means of making a differential diagnosis, the presence of 
initial fever and prodromata, the absence of disturbances of sensibility, of 
paralysis of the sphincters, and of a tendency to bed-sores in poliomye- 
litis anterior are of great aid in differentiating it from the results of caries 
of the spine, where rigidity of the limbs, increased reflexes, and contrac- 
tures are prominent symptoms. 

The differential diagnosis from cerebral paralysis is more difficult, as 
the condition of the limbs is similar in both. The diagnosis is made by 
the absence of all cerebral symptoms, and by the presence of such special 
symptoms as rigidity and prominence of the vertebrae in caries of the 
spine. 

Prognosis. — The prognosis is in general favorable. A certain number 
of cases remain uncured, but nearly all recover under treatment, although 
the condition may persist for months. 

Treatment. — The treatment of these cases is, as a rule, to be directed 
to the caries, and consists essentially in perfect rest on a rectangular bed- 
frame. Massage and electricity are sometimes of assistance when applied 
to the paralyzed limbs. Forcible correction of the deformity has the 
effect in many cases of improving the paralysis. When no improvement 
occurs after several months, laminectomy may be considered. 

OBSTETRICAL PARALYSIS. 

By obstetrical paralysis, or paralysis of the nevi-born, is meant thai form 
of peripheral paralysis which occurs during the delivery, and which, as a 
rule, affects the face or one of the extremities. In this sense it is to be 
separated from injuries to the brain and spinal cord which are produced 
during the delivery, — in fact, from any paralysis of central origin Avhich 
may occur in intra-uterine life, either before or at the time of delivery. 

Etiology and Pathology. — The cause of this form of peripheral paraly- 
sis is most often traction made upon the head of the child during delivery, 
thus producing a direct injury to the nerves, resulting either in pressure 
or stretching of the nerves, and in some cases in a rupture of the two 
upper roots of the brachial plexus. Although this form of paralysis has 
been known in a number of cases to result from pressure by the forceps 
during the delivery, yet it has also been met with after an apparently 
normal delivery, where the pressure did not seem to be especially severe 
or prolonged. 



DISEASES OF THE NERVOUS SYSTEM. 969 

When the nerves of the face are affected, the resulting lesion is supposed 
to be from an injury of the facial nerve ; and when the arm is affected, 
the lesion is supposed to be an injury of the brachial plexus or of the 
nerves in the lower part of the neck. As a rule, the lesion is of one arm. 

Symptoms. — A paralysis of this form usually becomes apparent imme- 
diately after birth, but may be delayed for several weeks. When the face 
is affected, it is due, as a rule, to an injury of the seventh nerve, thus pro- 
ducing a peripheral facial paralysis. The peripheral form of facial paraly- 
sis is distinguished from the central in that in the former all three branches 
of the seventh nerve are apt to be affected, while in the latter form only 
the lower tw T o branches are involved. In the peripheral form, therefore, 
the eye on the affected side cannot be closed entirely, causing the condition 
known as lagophthalmia, and there is inability to wrinkle the muscles of 
the forehead on the affected side. In facial paralysis of central origin the 
muscles of the forehead are not affected, and the ability to close the eye 
is but little decreased. 

Where the paralysis affects an arm it hangs lifeless by the side, with 
the palm turned backward and the fingers often flexed. The fingers and 
forearm may be moved, but the movement of the upper arm to any extent 
is lost. 

Diagnosis. — This form of paralysis is to be diagnosticated from cere- 
bral paralysis by the absence of increased reflex irritability and by the 
distribution of the paralysis. In the cerebral form all the muscles are 
affected ; in the peripheral form, only individual muscles, according to the 
extent and location of the lesion. It is doubtful whether paralyses of 
spinal origin occur in the early days of life. 

Cases of paralysis of the arm in the new-born should also be diag- 
nosticated from surgical injuries represented by fractures, dislocations, and 
separation of the epiphyses. 

Prognosis. — The prognosis, so far as the face is concerned, is very 
good, as the paralysis in these instances may last but a short time. We 
must, however, be somewhat guarded in the opinion which we give con- 
cerning these cases, as in some instances the paralysis does not disappear 
and the muscles of the face are left irreparably injured. 

In regard to the paralysis of the arm, in severe cases the prognosis is 
generally unfavorable, especially if marked improvement does not soon 
occur, and ordinarily when improvement takes place it is very slow. Most 
of these cases never recover completely, and even partial recovery should 
not be expected for a number of years. Shortening of the arm is marked 
in the later history of the severer cases. 

Treatment. — Electricity and massage should be begun after two or 
three weeks and may have to be continued for a long period. Continu- 
ously applied for a number of years they are a very important part of the 
treatment of these cases, and counteract the atrophy of the muscles from 
disuse, which must necessarily take place to a greater or less extent. 



970 PEDIATRICS. 

The following case is illustrative of the effects of obstetrical paralysis : 

A boy, two years old, was healthy at birth, but the labor was instrumental. 
When he was three days old it was found that his left arm was swollen. He was first 
seen at the hospital when he was seven weeks old. At that time he was able to move 
his fingers and wrist, but held his arm with the elbow straight to the side and the 
hand pronated. At the age of two years he was able to make slight movements of 
flexion of the elbow and slight contractions of the deltoid. Under the use of elec- 
tricity he showed gradual improvement. He could grasp objects fairly well with his 
left hand, could flex the elbow completely, and could raise his hand and forearm as far 
as the nipple. He could raise his right arm with ease to his head, but could not raise 
the left hand farther than the lower part of the chest. 

NEURALGIA. 

Neuralgia is a functional affection of the sensory fibres of the periph- 
eral nerves, represented by pain. Neuralgia is rare in infancy and early 
childhood. It may occur in very different localities, and may be repre- 
sented by intercostal neuralgia or the various milder forms of flitting pains 
in different parts of the body. 

Sciatica is a form of neuralgia which may occur in children, ana is 
characterized by neuralgic pain and tenderness in the course of the 
sciatic nerve, especially at its point of exit from the pelvis. 

In most cases of neuralgia temporary relief from the pain can be 
obtained by the use of phenacetine. It can be given in doses of 0.06 
to 0.3 gramme (1 to 5 grains), according to the age of the child. Its 
effects should be guarded by giving brandy and water. 

EPIPHYSEAL HYPEREMIA (Growing Pains). 

During the period of middle childhood children at times complain of 
pains in their limbs, especially the legs. In some cases these pains are 
probably closely associated with muscular rheumatism, since they may 
also occur in the joints. 

These indefinite pains are usually spoken of as u growing pains " but 
should be distinguished from rheumatism by their slight and evanescent 
character and by their lasting perhaps only for a few minutes or hours. 
They are supposed to be induced by fatigue and to be in some way con- 
nected with hyperemia of the epiphyses in the process of their develop- 
ment. 

HYDROCEPHALUS. 

By hydrocephalus is meant an accumulation of serous fluid in the 
cranium. This may occur either in the subarachnoid space (external 
hydrocephalus) or in the ventricles (internal hydrocephalus). 

When the accumulation of fluid represents the only pathological 
condition present the term primary hydrocephalus is used, while where it 
follows in the course of other diseases it is termed secondary. Hydro- 
cephalus may also be acute or chronic, congenital or acquired. 

Acute Hydrocephalus. — Etiology. — Acute hydrocephalus may be 



DISEASES OF THE XERVOCS SYSTEM. 971 

either external or internal, and is usually a combination of both. It is 
generally sudden in its onset, and while in some cases it may be idio- 
pathic (meningitis serosa), in most cases it is secondary to a number of 
conditions, such as cardiac disease, pertussis, rhachitis. neoplasms, tumors 
in the posterior fossa, acute inflammatory processes in the brain and its 
meninges, and acute febrile diseases, such as typhoid and pneumonia. 

Symptoms. — The amount of fluid in these acute cases is, as a rule, not 
large, 90 to 120 c.c. (3 or 4 ounces), and the symptoms are those 
which arise in meningitis when there is increased intracranial pressure, 
such as unequal pupils with sluggish reaction, optic neuritis, rarely con- 
vulsions, and cerebral paralyses, which are seldom severe or lasting. In 
mild cases recovery may take place in a few weeks, but in the more 
severe forms the increased intracranial pressure may prove fatal. 

Both the congenital and the acquired varieties of external hydrocepha- 
lus are so rare that they need not be more than mentioned as possibly 
occurring in certain congenital malformations, in atrophy of the brain 
{hydrocephalus in vacuo), and following cerebral hemorrhage. 

The general shape and circumference of the head in infancy and 
childhood vary normally in the individual to a considerable degree. On 
the other hand, when these variations in size pass a certain limit or are 
combined with certain nervous phenomena, they have a distinct patho- 
logical significance. 

Chronic Internal Hydrocephalus. — The chronic internal variety of 
hydrocephalus consists of a transudation into the cerebral ventricles. 
It may be congenital (infra-uterine) or acquired (extra-uterine). It may 
follow an operation for spina bifida or be produced mechanically by 
internal pressure from any cause. It may also represent the termination 
of an acute inflammatory process. 

The chronic form of acquired internal hydrocephalus resembles so 
closely congenital internal hydrocephalus that we can consider them 
together, and, so far as the name of the disease is concerned, the term 
hydrocephalus should be restricted to (1) congenital internal hydrocepha- 
lus and (2) chronic acquired internal hydrocephalus. In other words, 
there exists pathologically a certain class of effusions into the ventricles 
for which no cause is apparent. When these effusions reach a certain 
amount the resulting symptoms are quite typical of what is called hydro- 
cephalus, and clinically the term has therefore been confined to cases of 
this class. 

Pathology. — The anatomical appearance of the brain itself, as a rule, 
corresponds with and may be accepted as the result of pressure by an 
infra-ventricular fluid. Fig. 197, page 972, represents the brain of a 
child who died of congenital internal hydrocephalus, and well exemplifies 
the pathology of the disease. 

The convolutions are flattened and the walls of the ventricles are 
much thinned by the infra-ventricular pressure, while the ventricles 



972 PEDIATRICS. 

themselves are much dilated. In some parts the cortex is less than 1 
cm. (f inch) in thickness. The amount of fluid in these cases varies 
from a few cubic centimetres to three or four litres. The fluid has a 
specific gravity of about 1004. 

The earlier the hydrocephalic condition begins, the larger will the 
cranium become. We therefore find the very large heads, as a rule, to be 
of the congenital variety. The head is at times of such a size as to cause 
difficulty in the delivery, or the fluid may collect very rapidly after birth, 
and the head soon assumes the characteristic appearance of hydrocephalus. 

Figs. 198 and 199 represent the hydrocephalic skull at three years in 
comparison with a normal skull of the same age. 

The face in these cases of hydrocephalus remains about the same 
size as it would be normally, but usually looks much smaller from the 
disproportionate size of the head, which rests upon it like a globe. 

Symptoms. — The symptoms of congenital internal hydrocephalus are 
essentially those caused by pressure. We naturally, therefore, find the 
fontanelles bulging and fluctuating, and the bones thin and forced out of 
position. The temporal and parietal bones diverge as they extend up- 
ward, while in the normal skull they ascend almost perpendicularly. 

Fig. 197. 




Hydrocephalic brain. Warren Museum. Harvard University. 

This is shown in Figs. 198 and 199. If the disease has existed for some 
time, the upper Avail of the orbit becomes flat and the eyeballs protrude. 
The intra-cerebral pressure often produces a strong collateral circulation 
in the scalp and in the forehead, where the vessels appear like tortuous 
blue cords. Functional disturbances are numerous, and vary in almost 



DISEASES OF THE NERVOUS SYSTEM. 973 

every case. As a rule, the children are idiotic, but at times, even in 
marked hydrocephalus, Ave find the mental condition normal, even when 
paralysis is present. 

As the various cerebral centres become affected by pressure, symptoms 
arise corresponding to the parts of the brain Avhich are involved. Among 
these symptoms are nystagmus and, less frequently, strabismus. The 
pupils at first are usually moderately dilated. Later they become fixed, 
and sensibility to light is lost. The hearing lasts for a long time. The 
ability to walk is interfered with. Partial or general convulsions, paral- 
ysis (usually paraplegic), and contractures may occur. Pain in the head 
is often complained of, but, as a rule, is not so severe as in meningitis. 
There is difficulty in keeping the head erect, owing to its weight. The 
digestion is often good, and the appetite usually extreme. The res- 
piration is normal from adaptation. The pulse is usually not retarded. 
The temperature, as a rule, is normal. The adipose tissue is sometimes 
abnormally increased. 

Diagnosis. — As congenital internal hydrocephalus is almost invariably 
attended by enlargement of the head and separation of the sutures, the 
diagnosis is not especially difficult, and is determined by comparing the 
measurements of the head with those of a normal head of the same age. 
It must be remembered, however, that hydrocephalus may exist with a 
small head, and that the general shape and circumference of the head in 
infancy vary in the individual to a considerable degree. When, however, 
these variations in size pass a certain limit or are combined with certain 
nervous phenomena they have a distinct pathological significance. In 
addition to the enlargement of the head, the symptoms of direct intra- 
cephalic pressure make the diagnosis very simple. 

Prognosis. — These congenital cases, as a rule, die before childhood 
has been reached, but they have been known to live to middle age. 
Death usually occurs from some intercurrent affection. Complete re- 
covery is very rare. 

Treatment. — The treatment of congenital internal hydrocephalus has 
been varied, but without marked success. As a certain number of cases 
are due to syphilis, antisyphilitic treatment should always be tried. When 
the effusion is not large and is not increasing, moderate pressure with a 
rubber bandage seems to have a favorable result. When the disease is 
apparently not in an active state and is characterized by a very slight 
increase of fluid, aspiration through the anterior fontanelle of a small 
quantity of fluid at a time has been of temporary benefit. The point of 
aspiration should be 2 to 3 cm. (f inch to 1J inches) from the median 
line, so as to avoid puncturing the longitudinal sinus. 

An operation for chronic hydrocephalus presents no technical difficul- 
ties. Of course only certain cases are suitable for operation. Moderate 
effusions should be let alone, also those cases in which a rudimentary 
development of the brain is suspected. Cases in which an operation is 



974 



PEDIATRICS. 



especially indicated are both physically and mentally comparatively well 
developed up to the time when the enlargement of the cranium began.. 
Such children should show the symptoms of direct intra-cranial pressure. 
They gradually become weak-minded or idiotic. They do not learn to 
talk, or they quickly forget what they have learned. They may also 
become totally blind. The power of walking is interfered with. Con- 
tractions and partial and general spasms are of ordinary occurrence. 
Unless the pressure is speedily removed, atrophy of the brain results, and 
if they live they remain idiots for life. It may, however, be said that no 
brilliant results as yet have followed the operative treatment of hydro- 
cephalus. 

Fig. 200 represents a case of congenital hydrocephalus in an infant 
seven months old. 

Fig. 200. 




Congenital internal hydrocephalus. Male, 7 months old. 



It had always been nursed. When it was two days old it had convulsions. Three 
weeks later it had bronchitis, and accompanying this disease a return of the convul- 
sions, which occurred as often as six or seven 
times in the day. They were localized in the 
left arm and left leg. These convulsions lasted 
for three weeks, gradually growing less severe. 
There was at this time a certain amount of intes- 
tinal disturbance, which, however, disappeared 
later. There was also a history of a purulent 
discharge from the ears before the infant was 
admitted to the hospital. It cried out sharply at 
night. The measurements of the head were 56. 5 
cm. (22f inches) in circumference, and 36.7 cm. 
(14J inches) from ear to ear over the vertex. 
The anterior fontanelle was bulging. The eyes 
were markedly divergent and protruded from their 
orbits. 

Fig. 201 represents a child, five years 

Congenital internal hydrocephalus. old, with chronic hydrocephalus. 

Female, 5 years old. 

She was nursed by her mother for over a year, and cut her first tooth when she 
was six months old. She was always well and strong, but high-tempered. She had 
never had any other disease. When she was five months old she fell from her crib 
and struck her head, but it did not seem to hurt her especially. Her head was always 
noticed to be of a peculiar shape. When she was eight months old she fell out of a 




DISEASES OF THE NERVOUS SYSTEM. 975 

chair and was stunned, but was not otherwise hurt. She had convulsions from time 
to time, but her mind had always been bright. She was unable to hold up her head 
until she was three years old, and had always complained of more or less frontal head- 
ache. Her appetite had always been excessive, and her taste for food somewhat pecu- 
liar. She gradually grew stronger and was beginning to attempt to walk when last seen. 
She slept well and her bowels were regular. Her head measured 57 cm. (22J inches). 

The following case represents chronic acquired internal hydrocephalus 
in a boy four. years and eight months old. 

The child's parents were healthy ; his mother had other healthy children and had 
had no miscarriages. The child had always been well, measles being the only disease 
which he had ever had. At the age of six months, while in the process of cutting a 
tooth, he had three convulsions, from which he recovered entirely. His appetite had 
always been capricious, but his digestion was good. His bowels had always been reg- 
ular. He had lately come from a malarial region, where he had lived in a rather damp 
dwelling for a year. 

On May 6 he vomited twelve or thirteen times. The vomiting then stopped, but 
returned later from time to time. He complained of pain in his stomach, had no fever, 
and sometimes appeared to feel chilly. His bowels were constipated, and in the be- 
ginning of the attack his pulse was slow. He had been subject to night-terrors for 
some time previous to this sickness. The vomiting had lessened by May 27, and the 
report of my examination on that date is as follows : 

Pulse 60, rhythmical ; respirations regular ; temperature normal ; has had ear- 
ache lately ; no discharge from the ear since he was an infant ; the examination of 
the ear was negative ; yesterday morning he had a general clonic convulsion lasting 
for some time ; his tongue is slightly coated ; «he lies in an apathetic state ; though 
perfectly conscious ; he is losing in weight and strength, and has lost his appetite ; 
urine normal. Nothing abnormal is found on examination of the thorax or abdomen. 
The examination of the eyes, on June 15, showed that there was much swelling of the 
optic nerve, increased prominence of the retinal vessels, hemorrhages, and neuritis. 
The child seemed much brighter, and played about. His intelligence was perfectly 
good ; he had had no more convulsions and no paralysis, and seemed perfectly well, 
except that his pupils were dilated and he was totally blind. 

This child came to see me eight years later, when he was twelve years old. He 
had been and was at that time perfectly well. He was a bright, well-developed, healthy 
boy. His pupils reacted, but he had never recovered his sight. He weighed 19.8 
kilogrammes (90 pounds). His bowels were regular ; his appetite was good ; his knee- 
jerks were not increased ; his head measured 49 cm. (19£ inches). 

THROMBOSIS OF THE CEREBRAL SINUSES. 
Etiology. — Thrombosis of the cerebral sinuses is more frequent in in- 
fancy and early childhood than in adult life. It is caused by the forma- 
tion of an ante-mortem clot in one of the sinuses of the brain. As a 
primary condition it is exceedingly rare. It is usually secondary to some 
condition which has produced an extreme reduction of the child's vitality, 
such as profound anaemia, exhausting diarrhoea, or a collection of pus in 
any part of the body, but especially about the scalp, as in erysipelas. A 
purulent otorrhcea is perhaps the most common etiological factor. It is 
not necessary here to do more than refer to the traumatic cases of this 
disease, in which the ear and the scalp are involved, as in fracture, or in 



976 PEDIATRICS. 

which the thrombosis is caused by compression, as from a cerebral tumor. 
The pathology of the secondary cases includes the lesions of the different 
processes which have caused the thrombosis. The thrombosis may take 
place in any of the cerebral sinuses, and at times may occur in the course 
of a meningitis. When the thrombus is formed, the venous branches be- 
hind the obstruction become distended mechanically, and thus give rise to 
capillary hemorrhages and softening of the floor of the ventricles. When 
the thrombosis has taken place in the neighborhood of some inflammatory 
focus, such as a purulent otitis media, pyaemia may result. 

Symptoms. — The symptoms which existed in cases in which this condi- 
tion has been found on post-mortem examination are not such as to suf- 
fice for making a differential diagnosis during life between this and other 
intra-cranial conditions, such as occur in profound anaemia. When, how- 
ever, convulsions occur in an atrophic child, especially if there has been 
chronic trouble in the ear, we can suspect the presence of this condition 
after carefully differentiating all other causes. Cases of thrombosis of the 
lateral sinus may be suspected when there are symptoms of a severe 
purulent affection following a suppurative otitis, with involvement of the 
mastoid cells, and when there is tenderness over the external jugular 
vein. 

Prognosis. — The prognosis is usually fatal, except when the throm- 
bosis occurs in the lateral sinus and can be relieved by operation. Pitt 
reports the recovery of a boy ten years old who had chronic otorrhcea, 
followed by acute symptoms of fever and aural tenderness. Following 
these symptoms, a week later, he had a rigor, and optic neuritis was 
developed on the right side. Exploration of the lateral sinus disclosed a 
clot, which was removed, and the boy recovered. 

The following case of cerebral thrombosis came under my observation 
at the infant hospital : 

An infant, nine weeks old, was apparently strong and well up to January 16, when it 
began to lose in weight. By January 23 it had lost over 200 grammes (6f ounces) with- 
out showing any other symptom of disease. By January 27 it had lost 480 grammes 
(16 ounces). Two days later it was attacked with convulsions and died. The autopsy 
showed nothing abnormal except a capillary hemorrhage into the ventricles caused by 
a thrombosis of the straight cerebral sinus. 

The pathological diagnosis in this case was that of a sinus-thrombosis of undeter- 
mined origin, a condition which is exceedingly rare, and instances of which, established 
by autopsy, have seldom been reported. 

ATHETOSIS. 
Athetosis is a symptom, and not a disease, and is represented by con- 
tinuous incoordinate arhythmical movements of the extremities, the face, 
and the body. This condition may be acquired or congenital. The 
acquired form may follow cases of hemiplegia or diplegia, in which event 
it affects the paralyzed limbs. Certain cases of acquired athetosis occur 
without any accompanying paralysis. In congenital athetosis, and in the 



DISEASES OF THE NERVOUS SYSTEM. 977 

acquired form without paralysis, the symptoms usually begin in the first 
year. 

Pathology. — The pathological condition which exists in cases of athe- 
tosis is supposed to be a chronic cerebral irritation in the neighborhood 
of the basal ganglia and in the internal capsule. The condition as we see 
it clinically, therefore, is wholly a symptom of some organic lesion of the 
brain. 

Diagnosis. — The diagnosis of acquired- athetosis is made by the charac- 
ter of the movements. These are continuous, and are distinguished from 
those of chorea by being vermicular and less spasmodic. 

The diagnosis in cases of congenital athetosis is not difficult, as in no 
other disease does an infant present at birth these peculiar movements 
and this grotesque form of flexion and extension of the fingers and toes. 
The disease called congenital chorea, in which involuntary arhythmical 
movements exist, is distinguished from athetosis by the character of the 
movements, which in the former resemble those of ordinary chorea. 

Fig. 202. 






!* 

\ 



4*v 



L«_ 



Congenital athetosis. Female, 2 years old. 

Prognosis. — The prognosis of athetosis in regard to recover*} 7 is un- 
favorable. So far as the general health is concerned, the individual may 
develop fairly well and may live for years. 

Treatment. — There is no known treatment which has proved to be of 
benefit in children. As they grow older the training of the affected limbs 
may be undertaken, but, as a rule, the results are unsatisfactory. Massage 
and electricity have proved to be of no value. 

Fig. 202 represents congenital athetosis in a girl two years old. She never had had 
any acute disease. She was born after a normal labor, and had received no subsequent 
injury. She had never talked nor shown much interest in her surroundings, nor had 
she been able to sit up or hold up her head without support. The bowels had always 
been regular and the appetite good. She was well developed and well nourished. 

The disease was characterized by the continual incoordinate arhythmical move- 

62 



978 PEDIATRICS. 

ments of the head, trunk, and extremities ; these movements were often quite rapid. 
There were constant flexion and extension of the hands and fingers, the fingers at times 
being bent backward and assuming most grotesque positions. This phenomenon was 
also seen in the toes. The expression of the face was not that of ordinary intelligence. 
The reflexes, on account of the resistance of the child to examination, could not be 
determined. She was usually irritable, but occasionally smiled slightly, and took 
some slight notice of those who were near her. 

INTRA-CRANIAL TUMORS. 

Etiology. — In infancy and early childhood tumors of many varieties 
may occur in the brain and its meninges. The most common form of 
intra-cranial tumor is tubercular. The next in frequency are glioma, 
sarcoma, and glio-sarcoma. The other varieties, such as carcinoma, 
lipoma, myxoma, and teratoma are very rare ; syphilitic gumma, which 
is so frequent in adults, is exceedingly rare in infancy and early child- 
hood. The parasitic cysts in the brain which occur quite frequently in 
individuals in other parts of the world, especially in Germany, are seldom 
met with in this country. 

These tumors may be either of intra- or extra-uterine origin. Of 
these the tubercular is the most common. 

Pathology. — The tubercular tumors of the brain or its meninges are T 
as a rule, secondary to a tubercular growth in some other part of the 
body, or to tubercular disease of some part of the skull, such as the 
orbit or ear. These tubercular tumors may be single or multiple, the 
latter being the more common variety. They may be found in any part 
of the brain or its meninges, and occur with especial frequency in the 
cerebellum. They may vary in size from a small collection of miliary 
tubercles to much larger masses. When one or more cheesy masses of a 
tubercular nature are found in different parts of the brain, the condition 
is called solitary tubercle. The gliomata grow most frequently in the 
white substance of the brain, but sometimes develop in the gray matter. 
According to Starr, they grow less rapidly than sarcomata, and never 
involve the membranes. They are usually primary, but may develop 
secondary to glioma of the retina (Starr). The sarcomata are both of 
the round-celled and of the spindle-celled variety. Although not quite 
so frequently found as the gliomata, they are more frequent than the glio- 
sarcomata or myxomata. They are usually round in shape, develop 
both in the nervous tissue and in the cerebral membranes, and in both 
the white and gray matter of the cerebrum and cerebellum. The other 
varieties of tumor of the brain are so rare that they need not be con- 
sidered here. 

Intra-cranial aneurisms are rare in childhood and are never very 
large. They are found in the larger arteries of the base of the brain and 
in the Sylvian arteries. 

Symptoms. — The general symptoms vary very much in accordance with 
the size and vascularity of the tumor, and according as it is growing or has 



DISEASES OF THE NERVOUS SYSTEM. 979 

become stationary. In the former case the symptoms are often apt to be 
more severe than later, when, the tumor having become stationary, the 
brain-tissue adapts itself to the new conditions produced by the morbid 
growth. Intra-cranial tumors in infants and in young children are often 
latent, present no symptoms, and are sometimes discovered only after 
death. A certain number of cases, on the other hand, present only 
general symptoms, such as headache, cerebral vomiting, attacks of vertigo, 
convulsions, and optic neuritis, which cause us to suspect intra-cranial 
disease, but give an indefinite idea of its location. Again, these tumors 
may produce local symptoms in addition to the general ones. These 
local symptoms are represented by paralyses of different kinds, anomalies 
of sensation, affections of the special senses, and staggering. These 
later symptoms arise according to the site of the tumor and the parts of 
the brain which are affected by it, and by means of them we can more or 
less approximately judge of its situation, size, and rapidity of growth. 

Paralyses of the extremities are caused by an affection of the motor 
cortex, the internal capsule, or any portion of the motor tract on the 
opposite side of the brain, above the crossing of the pyramids. Stagger- 
ing or ataxia is suggestive of cerebellar disease, while the involvement of 
the intra-cranial nerves suggests a tumor of the base of the brain or 
pressure on these nerves at some point, and more rarely an affection of 
their nuclei. The tendon reflexes are apt to be exaggerated, but in some 
cases are normal, and in others are said to be absent. The symptoms of 
cerebellar ataxia which at times occur when the tumor is situated in the 
cerebellum consist of a staggering gait resembling that of an intoxicated 
person, the steps being irregular in length and the body swinging from 
side to side. The child in these cases has a subjective sense of falling or 
turning back, and grasps for support or sinks into a chair or to the floor. 
This form of ataxia is to be distinguished from that which is found in 
spinal disease, where it is due to an inability to co-ordinate properly the 
muscles of the lower extremities. This latter form of ataxia is much more 
regular than the former, each step being insecure and unsteady, but with- 
out the violent and sudden reeling, after two or three steady steps, which 
occurs in the cerebellar form. In young infants a tumor may cause a pro- 
tuberance of some part of the skull by pushing one of the bones outward. 

Diagnosis. — The diagnosis of tumors of the brain must in the great 
majority of cases be made by elimination. The variety of tumor can be 
determined most readily by considering the history of the case, as to 
whether it is tubercular, syphilitic, or • otherwise. The diagnosis of a 
tumor can often be made by the slow and gradual development of the 
disease. When severe headache and vomiting exist, followed by paraly- 
sis, either monoplegic or hemiplegic, especially if this paralysis develops 
slowly, we should suspect the presence of some form of intra-cranial 
growth. This suspicion is much strengthened by the presence of optic 
neuritis or optic atrophy. The presence of localized convulsions in such 



980 PEDIATRICS. 

cases tends to confirm the diagnosis, while if marked ataxia exists we are 
justified in suspecting cerebellar disease. A normal or only slightly ele- 
vated temperature with these symptoms also points to the diagnosis of a 
cerebral tumor. 

Prognosis. — The prognosis of tumors in early life is very unfavorable, 
no matter what the variety of the tumor may be. Although the patient 
may for a long time remain wholly unaffected by the morbid growth, he 
eventually, except in rare cases, succumbs to the disease. 

Treatment. — Surgical interference in children, as in adults, proves, on 
the whole, to be the most valuable means at our command for lengthening 
life in cases of cerebral tumors, but the results have not been what was 
hoped for when cranial surgery came first into prominence. There is no 
other treatment which is of any especial benefit in either retarding the 
growth or curing this class of cases. Where the exceedingly rare form 
of syphilitic gumma exists, iodide of potassium may be of much value, 
and is indicated as in adults. 

The following case was one of solitary tubercles of the brain : 

An infant, thirteen months old, had never had any especial disease, and entered 
the hospital weak and emaciated. Its mind was clear. Its pulse was weak but regular, 
and neither slow nor rapid for its age. Its temperature was at times somewhat raised, 
varying from 37.2° to 38.4° C. (99° to 101° F.). There were no convulsions, and no 
paralysis or contractures, but merely progressive loss in weight, and finally death. 

An examination of the brain showed miliary tubercle of the pia mater at the base 
of the brain without acute inflammation, which accounted for the lack of acute cerebral 
symptoms. Of especial interest, however, in the case were some patches of solitary 
tubercles, 1.2 cm. (| inch) in diameter, in the left temporal and occipital lobes and in 
the right frontal lobe of the cerebrum, and also in the lower left cerebellum. There 
were also caseous tubercles of" the post-bronchial lymph-nodes, tubercles of the lungs 
with a slight amount of broncho-pneumonia, miliary tubercles of the pleura, liver, and 
spleen, and caseous tubercles of the mesenteric lymph-nodes. 

CEREBRAL SYPHILIS. 

Intra-cranial syphilis may be either congenital or acquired. Accord- 
ing to Bullard, the intra-cranial lesions are essentially the same in both 
forms. 

Pathology. — Intra-cranial syphilis may be divided pathologically into 
three forms : (1) diffuse inflammation of the meninges or their neighbor- 
ing tissues, (2) localized growths or tumors (gummata), and (3) syphilitic 
endarteritis. In the latter case (endarteritis) there may be local dilatation 
or local occlusion of the blood-vessels. These conditions are apt to 
occur simultaneously. When the dilatation reaches an advanced stage a 
thinning of the arterial Avails results, which may lead to rupture of the 
blood-vessels or to hemorrhage. More common than the hemorrhage, 
however, is the occlusion of the blood-vessels, which cuts off the blood- 
supply and acts in the same way as in other cases of thrombosis of the 
arteries, causing more or less softening and disintegration of the cerebral 



DISEASES OF THE NERVOUS SYSTEM. 981 

tissues supplied by them. The arteries of the base of the brain are the 
ones that are most frequently affected, and there are secondary lesions of 
the parts of the brain supplied by them. 

Symptoms. — The symptoms dependent on these lesions vary in accord- 
ance with the pathological condition. 

In syphilitic meningitis the principal symptoms are severe headache in 
various parts of the head, more or less constant, lasting for many days or 
even weeks, and frequently accompanied after a time by paralysis of 
some of the intra-cranial nerves, especially of the third or of the seventh. 
As in other cases of meningitis, the optic nerves may also be affected, 
and the child shows the general symptoms of a severe intra-cranial affec- 
tion, such as vomiting, dulness, headache, and localized paralyses. 

The localized tumors or gummata present essentially the same symp- 
toms as other forms of tumors of the brain. 

The symptoms produced by syphilitic endarteritis vary according to 
the areas of the brain affected, but the most common ones are the 
various forms of paralysis of the extremities and sensory disturbances. 

Diagnosis. — In regard to the diagnosis of cerebral syphilis in children, 
the symptoms differ greatly in different cases. The most characteristic 
group of symptoms, and one which is exceedingly suggestive of intra- 
cranial syphilis, includes attacks of organic paralysis, central in origin, 
occurring at intervals of days or months without known cause, and with- 
out marked symptoms of either tumor or tuberculosis 

The diagnosis of syphilitic meningitis may be made from the occur- 
rence of severe headaches, followed by paralysis of one or more of the 
motor cranial nerves, and occurring without marked rise of temperature. 

Gummata present no especial symptoms from other intra-cranial 
tumors. The presence of syphilitic lesions elsewhere is our principal 
ground for making the diagnosis. 

Syphilitic endarteritis may be suspected when an acute affection in the 
neighborhood of the pons or medulla not produced by traumatism occurs 
in a syphilitic subject, or when acute symptoms suggestive of hemorrhage 
or embolism occur, and when no other probable cause can be shown, 
such as cardiac or renal disease. 

Prognosis and Treatment. — The results of antisyphilitic treatment in 
these cases are sometimes striking. The treatment should be pushed to 
the limit of tolerance. 

MENINGITIS. 
Although inflammation of the meninges may occur secondarily to 
disease of the brain itself, and may affect either the dura mater or the 
pia mater, yet clinically by far the most common condition met with 
in early life is a leptomeningitis forming itself the most important part of 
the morbid process. Pachymeningitis is in early life so rare, except from 
traumatism or as a lesion of some specific disease such as syphilis, that it 
need simply be mentioned as of possible occurrence. 



982 PEDIATRICS. 

The term meningitis may represent a number of diseases, and the 
symptoms in all are very similar and depend largely on the intensity of 
the inflammation and on the parts of the brain affected. 

The disease may be caused by various specific organisms, such as the 
tubercle bacillus, the diplococcus intracellularis, the pneumococcus, the ty- 
phoid bacillus, the influenza bacillus, and others, or it may be secondary 
to other diseases or lesions of traumatic origin. These secondary forms 
are grouped under the head of simple acute meningitis. Tubercular 
meningitis has been described on page 406 and cerebro-spinal meningitis 
on page 432. 

Simple Acute Meningitis. — Etiology. — An acute meningitis may 
arise in the course of a number of infectious diseases, such as erysipelas 
or ulcerative endocarditis ; also after insolation and injuries to the head. 
It may attack robust as well as debilitated children, and may occur at all 
ages. It is rare in the first year of life. It is most common in the 
middle period of childhood. It is especially liable to arise from an ex- 
tension of the inflammation from disease of the ear, and this in young 
subjects may take place through the unclosed petrosquamosal suture. 

According to Sachs, the cases of idiopathic meningitis which have been 
reported, which are not due to the specific organisms already described, 
are probably due to some slight traumatism which has passed unnoticed. 

Pathology. — The pathology of simple acute meningitis is practically, in 
infants and young children, an inflammation of the pia mater, but there 
is also usually a mild grade of inflammation of the dura and of the gray 
matter of the brain. It may be acute or chronic. It is, as a rule, non- 
purulent in character. The arachnoid may appear somewhat opaque and 
the cerebral substance oedematous. There is an increase in the cerebro- 
spinal fluid and the ventricles may be so distended as to correspond to an 
acute hydrocephalus. The pia of the convexity is most frequently 
affected, while that of the base may be entirely free, with possibly a 
slightly increased exudation of lymph in the interpeduncular space. 

There is usually an extravasation of white blood-corpuscles near the 
blood-vessels, which are found on microscopic examination to be slightly 
engorged. When the meningitis has lasted for a time, the pia, because 
of the agglutination which has taken place, cannot be removed without 
injuring the gray matter. In any case of acute meningitis the inflam- 
mation is apt to extend downward and to involve the pia mater of the 
cord. 

In the chronic form the pia mater at the base of the brain alone may 
be inflamed (basilar meningitis), or the lesions may be found distributed in 
small or large areas over the convexity. In these cases the pia mater is 
thick and opaque, and there is a production of pus, fibrin, and serum, with 
a formation of new connective tissue. The relative quantity of these in- 
flammatory products varies, and sometimes results in firm and extensive 
adhesions between the dura and the pia mater. Other conditions which 



DISEASES OF THE NERVOUS SYSTEM. 983 

represent the results of chronic inflammation may also be present, but 
need hardly be referred to here, further than to say that the ventricles of 
the brain may in this chronic form contain an increased amount of serum 
and may be dilated. The ependyma also may be thickened and rough- 
ened. 

Symptoms. — Where acute simple meningitis is secondary to injuries or 
to other diseases, the characteristic symptoms may, of course, be compli- 
cated and even obscured by those of the primary cause. The symptoms, 
however, are very similar to all the other forms of meningitis which have 
been described under specific infectious diseases except that they corre- 
spond to an inflammatory condition of the convexity rather than to that 
of the base. The course is often short, sometimes not more than seven 
or eight days. The disease may, however, prove fatal in forty-eight 
hours ; on the other hand, it may last a number of weeks. When the 
convexity is chiefly affected, the onset is characterized by intense head- 
ache, vertigo, vomiting (usually of a cerebral type), and a high tempera- 
ture, 40° to 41.1° C. (104° to 106° F.). The respirations are rapid, 
30 to 50, and comparatively regular. The pulse in the early stages is 
rapid, 150 to 170, but is usually regular; later it becomes irregular and 
slow. Convulsions occur early in the attack. Irritability, listlessness, 
apathy, and drowsiness subsequently develop. The pupils are contracted 
at first, but later become dilated ; delirium appears ; rigidity of the neck 
is present, and in some cases a marked spastic condition of the lower 
extremities. The deep reflexes are usually increased ; the abdomen is 
retracted, and the bowels are constipated. 

All these symptoms develop rapidly in a few days, and then are in- 
tensified as the disease progresses. Blindness (from optic and ocular 
paralyses) in the form of strabismus and ptosis may appear. A tache 
cerebrale is apt to be found, but is not diagnostic. A monoplegic or 
hemiplegic paralysis having all the symptoms of a cerebral paralysis may 
develop. In favorable cases the symptoms lessen in severity, and the 
rigidity, blindness, and paralysis gradually disappear as the child comes 
out of its coma. In fatal cases the symptoms grow still more severe ; 
the rigidity and retraction of the neck increase ; opisthotonos may occur, 
and the respiration assumes a markedly Cheyne-Stokes type until it 
ceases at death. Photophobia, contracted pupils, and delirium are 
present. 

Diagnosis. — Great caution should be used in differentiating a simple 
acute meningitis from the cerebral symptoms accompanying so many acute 
infectious diseases, for the symptoms are often very similar. Other dis- 
eases should therefore first be excluded. 

The form of meningitis which is to be especially differentiated from 
simple meningitis is the tubercular, in which the symptoms correspond 
more to lesions of the base of the brain as described on page 415. 

Prognosis. — The prognosis is very unfavorable. It is possible, how- 



984 PEDIATRICS. 

ever, for the child to recover completely. Perhaps only a changed men- 
tal condition will remain, boys appearing effeminate or more easily excited 
than would be considered normal. Some of the more acute forms affect 
also the brain, and we find their results in idiocy and contractures. 

Treatment. — The treatment of simple acute meningitis varies with that 
of the disease or condition to which it is secondary. The child should 
be kept in a cool, dark room and protected from noise. In the treatment 
of meningitis, whether primary or secondary, the indications are to re- 
duce the temperature of the body and to support the general strength 
until the disease has run its course. The former is accomplished best by 
sponging the entire body every three or four hours with water at a tem- 
perature of from 15.55° to 22.22° C. (60° to 70° F.), and by the appli- 
cation of cold to the head preferably by Letter's coil. The strength 
should be supported by the administration of milk, and, when necessary, 
of stimulants. 

The bowels should be freely moved with some purgative such as calo- 
mel. Bromide of soda in doses varying from 0.3 gramme (5 grains) to 
0.6 gramme (10 grains) should be given according to the age of the child, 
and every four to six hours according to the severity of the symptoms. 

In cases of recovery the greatest care should be taken to keep the 
child free from excitement for many months, and to insure an absolutely 
restful life with freedom from physical fatigue. Massage and electricity 
should be used where there are paralysis and contractions. 

ACUTE ENCEPHALITIS. 

Although this disease is frequently associated with leptomeningitis, 
and may occur by simple extension in meningitis due to traumatism or 
to acute or chronic intoxication, it may also occur, according to Sachs, 
independently of meningeal lesions, and usually before puberty. 

Symptoms. — For a few days headache, dizziness, irritability or depres- 
sion are noticed. The drowsiness increases to coma, but the loss of 
consciousness need not be complete, and remissions may be distinct in 
the first week of the disease. The pupillary reflexes are normal or slug- 
gish ; the deep and superficial reflexes are not altered. Rigidity of the 
neck and opisthotonos, monoplegia, or hemiplegia develop early, and 
aphasia may or may not be present. Ocular and cranial paralyses occur 
and simulate basilar meningitis, excepting that the loss of consciousness is 
not complete. The respiration may become irregular and the pulse slow, 
rapid, or irregular. The symptoms vary according to the lesions, whether 
they are of the convexity or base. The disease may last two or three 
weeks and then prove fatal, or there may be prolonged remissions and 
complete recovery. 

Strumpell, Furbringer, and others have endeavored to establish a form 
of acute hemorrhagic encephalitis developing commonly after some acute 
infectious disease, especially influenza, and the pathology is supposed to 



DISEASES OF THE NERVOUS SYSTEM. 985 

consist in small and strictly circumscribed inflammatory areas which may 
be developed in symmetrical parts of the brain. 

Prognosis. — The prognosis is bad according to the intensity of the 
symptoms and the degree of septicaemia present. 

Treatment. — The treatment should be such as has been described for 
simple acute meningitis. 

BULBAR PARALYSES. 

Diseases of the pons and medulla are very rare, but may occur in 
children with the same symptoms as in adults. They need not be more 
than mentioned. 

Polio-encephalitis, superior and inferior, and the acute and pseudo-bulbar 
paralyses occur so rarely in early life that they hardly have a place in the 
nervous diseases of childhood. 

MULTIPLE NEURITIS. 

Neuritis is an inflammation of the peripheral nerves. It is accom- 
panied by pain and tenderness in the affected regions, and in the more 
severe cases by paralysis and atrophy. Neuritis of a single nerve-trunk or 
of its branches may be caused by traumatism, cold, or pressure, or may 
occur in the course of various diseases. In certain constitutional condi- 
tions a number of nerves in different parts of the body are affected with 
neuritis, constituting the disease called multiple neuritis. 

Etiology. — Multiple neuritis usually occurs in the course of or subse- 
quent to one of the infectious diseases. Of these diseases diphtheria is 
the most common, but it is said to follow scarlet fever and measles. A 
mild form sometimes occurs after typhoid fever. At times multiple 
neuritis is produced by drugs, such as lead, arsenic, or alcohol. It is not 
a common disease among children. The epidemic form of the disease, 
known by the terms kakke and beri-beri, is quite rare in this country. 

Pathology. — The pathological condition in multiple neuritis is an in- 
terstitial or parenchymatous inflammation of the nerves. A few nerves 
may be affected, or the distribution may be general. The nerves of the 
special senses, however, are rarely affected, and the nerves of the head 
and face are not usually involved. 

Symptoms. — The onset of the disease may be acute or subacute, but in 
most cases the onset is gradual. It may at the beginning present severe 
symptoms, such as extreme pain, tenderness over the nerve-trunks, and 
fever with an accompanying paralysis. On the other hand, the pain in 
the beginning may be very slight, and the first symptoms noticed may be 
a gradually increasing weakness of the limbs, while the tenderness may 
be found only when especially sought for. There may be hyperesthesia, 
anaesthesia, numbness, and loss of muscular power. Both the sensory and 
motor nerves are affected and the condition is symmetrical. After the 
acute symptoms have passed away the faradic irritability is diminished : the 
action of the nerves to the galvanic current is diminished, and the reaction 



986 PEDIATRICS. 

of degeneration is present. When the extensors of the leg are affected 
there is foot-drop, and when those of the forearm are affected there is 
wrist-drop. All the muscles, although rarely, may be affected and the 
child may become perfectly helpless. The course of the disease is apt to 
be a long one of several months, and in the later stages atrophy occurs, 
while the early hyperesthesia may give place to a more or less marked 
anaesthesia, and numbness and various other paresthesias may occur. In 
mild cases, where only pain and tenderness exist, the knee-jerks are not 
diminished, and may be even slightly increased, but in the more typical 
cases of the disease they are absent. Contractures and spasmodic condi- 
tions are absent, the paralysis being flaccid. The bladder and rectum are 
not affected. The temperature is apt to be somewhat raised, and is 
decidedly so at the onset when the disease is acute. The sensory symp- 
toms are most marked in the beginning of the attack and improve and 
subside more rapidly than the motor. 

Diagnosis. — The diagnosis is made by the same nerve areas being 
affected by sensory and motor symptoms and by the persistent sensitive- 
ness of these areas. In certain cases poliomyelitis may simulate mul- 
tiple neuritis, the former being distinguished by the vague pains instead 
of the pain definitely following the nerve-tracts, by the limited distribu- 
tion of its paralyses, and by its lack of symmetry. The electrical reac- 
tions are much the same in both diseases. 

The disease might in some cases be mistaken for a form of acute 
ascending paralysis, known as Landry's paralysis. The latter condition 
is, however, exceedingly rare in children. Landry's paralysis begins in 
the legs, involving successively the muscles of the abdomen, thorax, 
upper extremities, pharynx, larynx, and eyes. The rapid and progressive 
character of the paralysis and the absence of sensory symptoms are the 
main points of difference between the two conditions. If Landry's 
paralysis is made to include cases with sensory symptoms, as is some- 
times done, the differential diagnosis from multiple neuritis may at times 
be impossible. 

Prognosis. — The prognosis of multiple neuritis is favorable even 
when the disease begins with an acute onset accompanied by delirium 
and high fever, and, although the paralysis may last for many months, 
the cases usually recover. Exceptionally, however, the paralysis may be 
permanent, and death may take place from paralysis of the heart or of the 
muscles of deglutition and respiration. When the reaction of degenera- 
tion is present the prognosis for complete recovery is not so good and the 
case is apt to be prolonged. 

Treatment. — The treatment is at first by absolute rest in bed, and 
later with electricity, massage, and strychnine. The primary cause of 
the disease having been determined, such cause should, if possible, be 
removed. For instance, if the child lives in a malarial district it should 
be removed. 



DISEASES OF THE NERVOUS SYSTEM. 987 

The treatment of those cases which follow the acute infectious dis- 
eases is symptomatic and hygienic. For the pain the application of heat 
is the most efficacious remedy. In the acute cases electricity should be 
begun after three or four weeks ; faradism should be used if a reaction is 
obtained with a moderate current, otherwise galvanism. 

Iodide of potassium is indicated in those cases which are caused by 
lead or arsenic. 

In the subacute cases electricity and massage should be employed 
from the very beginning. 

It is safer to wait until the pain and marked tenderness have disap- 
peared before beginning the administration of strychnine. 

The following case, a girl, eleven years old, represents multiple neuritis produced 
by doses of 1 gramme (15 minims) of Fowler's solution given three times a day for 
some weeks during an attack of chorea. 

The first symptoms which were noticed while she was taking the arsenic were that 
she vomited several times, but this was not supposed to have been caused by the arsenic, 
and the drug was therefore continued. It was next noticed that the child was unable 
to walk. Her limbs appeared to be very weak, and there was absence of knee-jerks 
and ankle-clonus. The sensation of the limbs was normal. A few days later she was 
found to have tender points over various parts of the legs. The legs then became 
atrophied. About a month later tender points developed in the arms, and she soon 
lost the power of using her arms, to such a degree that she had to be fed. At this 
time, although the arsenic had been omitted for several days, a large quantity of it was 
found in the urine. 

One month later it was found that she could almost support herself without assist- 
ance. A little later she walked with crutches, and a month later she could walk with- 
out assistance, but with difficulty. The knee-jerks were still absent. She continued 
to improve, and finally after a number of months recovered entirely. 

INSULAR OR DISSEMINATED SCLEROSIS. 

Insular or disseminated sclerosis is a chronic degenerative disease of 
the brain and cord, characterized by multiple distribution of areas of 
sclerosis. 

Etiology. — The disease appears most frequently as a result of the spe- 
cific infectious fevers. Heredity is of some importance in the etiology, 
chiefly inasmuch as it predisposes to a neurotic disposition. The disease 
is most common in the second and third decades, but many cases in 
early life, even in infancy, have been reported. 

Pathology. — The sclerotic patches may occur in the brain or cord or 
in both, and are very irregular in their distribution. The white matter of 
the brain, the pons, the medulla, and the lateral columns in the dorsal 
and lumbar regions are most commonly involved. The sclerosed patches 
consist of proliferated neuroglia, the growth of which destroys the me- 
dulla of the nerves with but little destruction of the axis-cylinder. 

Symptoms. — The disease is generally slow in its development, and is 
characterized by tremors on attempting voluntary motions {intention 
tremors) ; by scanning speech, the words being pronounced slowly or with 



988 PEDIATRICS. 

accentuation of the syllables and distinct tremulousness of the voice ; 
by nystagmus, a rapid oscillatory movement of the eyes, especially when 
they are moved laterally ; and by spastic paralysis, the gait being clumsy 
and staggering. The muscles are rigid and the deep reflexes increased. 
Ocular disturbances are common and are similar to those observed in 
hysteria. Inequality of the pupils and atrophy of the optic nerve may 
occur. In the majority of cases there is no disturbance of sensation. 

As the disease progresses the speech becomes unintelligible, the mem- 
ory fails, and the muscular weakness and paralysis is more and more 
marked until the patient is bedridden. Some cases are of more rapid de- 
velopment than others. Some may present bulbar symptoms in which 
not only the power of speech but of deglutition and respiration is affected. 

Diagnosis. — A marked degree of muscular atrophy, paralysis of the 
bladder and rectum, and changes in electrical reaction are not present in 
multiple sclerosis, and their absence is of much aid in the differential 
diagnosis. 

Multiple sclerosis may be distinguished from transverse myelitis by 
the extreme rarity of the latter condition in early life, by its acute onset, 
the involvement of the bladder, and the sensory symptoms. 

The diagnosis from hereditary ataxia is given on page 989. The nys- 
tagmus, scanning speech, and intention tremor will serve to distinguish the 
disease from hysteria, which it may at times resemble. Chorea may be 
eliminated in the diagnosis by the absence of tremor, by the presence of 
the characteristic incoordinate movements, and by the absence of nystag- 
mus and true ataxia. 

Prognosis. — The disease is incurable, and may last for years. Remis- 
sion of the symptoms and even improvement may occur, but the general 
course of the disease is progressive. 

Treatment. — Rest in bed, hydrotherapeutics, massage, and general 
hygiene are desirable in that they alleviate the condition, rendering life 
more bearable, but no treatment can be said to be in any way curative. 

HEREDITARY ATAXIA (Friedreich's Disease). 

Hereditary ataxia is a very rare disease, dependent on a slowly pro- 
gressive sclerosis of the cord at different levels, which involves especially 
the posterior and lateral columns. It usually occurs in several members 
of a family, and develops in late childhood. 

Symptoms. — The characteristic symptoms are ataxia of the legs and 
arms, gradual loss of muscular power, with atrophy of the muscles, loss 
of the knee-jerks, disturbance of speech, and, in the late stages, nystagmus, 
muscular contractures, from muscular paralyses, and complete helpless- 
ness, with mental impairment. 

A cerebellar form of the disease has been described, characterized by 
an increased knee-jerk, loss of ocular accommodation, light reflexes, and 
absence of deformities. 



DISEASES OF THE NERVOUS SYSTEM. 939 

Diagnosis. — The disease is differentiated from tabes dorsalis by the 
absence of the crises and Argyll-Robertson pupil of tabes, by the heredi- 
tary character of the affection, and the extreme rarity of tabes in early life. 
It is differentiated from multiple sclerosis by the absence of increased 
reflexes, intention tremors, spastic gait, and ocular palsies. 

Prognosis and Treatment. — The prognosis and treatment of hereditary 
-ataxia is always unfavorable, and no treatment is of benefit except for the 
relief of symptoms. 

LOCOMOTOR ATAXIA. 
Locomotor ataxia, or tabes dorsalis, is almost unknown in childhood. 
The very rare cases resembling it probably represent entirely different 
lesions from those which are found in cases of the disease occurring in 
adults. 

SYRINGOMYELIA. 
Syringomyelia is exceedingly rare in early life. It is regarded as a 
gliosis, a development of embryonal neuroglia tissue about the central 
canal of the spinal cord, in which hemorrhage and degeneration takes 
place with the formation of cavities. 

In this disease we usually find a diminution of sensation to heat and 
cold, according to the site of the lesion, which is commonly a point in 
the upper dorsal or the lower cervical region. There is apt to be a weak- 
ness of one or both arms, accompanied by marked wasting. There is 
also usually some weakness in the legs. The reflexes are increased, and 
a spastic condition is likely to result. These symptoms are usually ac- 
companied by marked lateral scoliosis. 

Syringomyelia is an incurable disease, and the treatment is therefore 
usually limited to correcting, if possible, the lateral curvature which fre- 
quently accompanies it. 

HEREDITARY SPASTIC PARALYSIS. 
The term hereditary spastic paralysis has been applied by Sachs to an 
hereditary disease characterized by spastic rigidity, chiefly of the lower 
extremities. He recognizes two types of the disease. One is of spinal 
type, a spastic paraplegia with contractures and increased reflexes, due to 
interference with the pyramidal tract in the lateral column of the cord. 
Another type, the cerebral type, develops at about four or five months of 
age. It is characterized by increasing mental dulness, defective vision, 
ending in blindness, nystagmus, and gradual physical deterioration. Con- 
vulsions are never present. The symptoms may continue for one or two 
years, but end fatally. The treatment is symptomatic. 

PROGRESSIVE CENTRAL MUSCULAR ATROPHY. 
Progressive muscular atrophy of central origin, also described as the 
Aran-Duehenne type, develops in the great majority of cases in adult life 
after the twenty-fifth year. A few cases, however, have been reported 



990 PEDIATRICS. 

in young children, notably two by Hoffman, one of which occurred in a 
girl four years of age, and another in her brother, in whom the symptoms 
began at about the same age. 

Various forms are recognized in adults and are known as amyotrophies, 
by which is meant a progressive wasting due to lesions in the spinal cord, 
as distinguished from the term myopathies or dystrophies, in which the pri- 
mary disease is in the muscles themselves. Midway between these two 
types of muscular atrophies, both in the pathological lesions and clinical 
symptoms, is another, which will be described later as progressive neural 
muscular atrophy. 

Etiology. — The direct cause of the progressive muscular atrophy of 
central origin is not known. Hereditary and family influences are, in 
adults, of much less importance in relation to this spinal type of progres- 
sive muscular atrophy than they are in the muscular atrophies of neural 
origin and of the dystrophies. The association of the disease, however, 
in the children of one family has been noted, and is a characteristic of 
the infantile form. Trauma, exposure to wet, cold, fright, and nervous 
shock are mentioned as etiological factors. 

Pathology. — The pathological lesions consist primarily in a slow de- 
generation of the upper and lower neurons of the motor path, resulting 
in progressive atrophy of certain groups of muscles. The chief histologi- 
cal changes consist of an atrophy of the ganglion-cells of the anterior 
horns and an increase in the neuroglia. The lateral pyramidal tracts 
show degenerative changes, which, in some cases, have been traced to 
the motor cortex, and even to the cortical motor cells themselves. The 
direct cerebellar and ventro-lateral tracts are not involved. The muscles 
and the inter-muscular branches of the motor nerves show degenerative 
changes. 

Symptoms. — Indefinite pains suggesting those of chronic rheumatism 
may be the earliest symptoms. These are followed by a gradual loss of 
power and atrophy of the muscles. The muscles of the thumb, both in 
the thenar and hypothenar groups, and then the interossei and lumbri- 
cales are first affected, leaving depressions between the metacarpal bones. 
The wasting process then attacks the flexor and extensor muscles of the 
forearm, contractions set in, and the characteristic " claw-hand" develops. 
The deltoid is the first of the shoulder muscles to atrophy, and then 
follow in the typical cases the remaining muscles of the upper extremity, 
the muscles of the trunk, and finally those of the lower extremity. The 
trapezius and face muscles are among the first to be attacked. This order 
of progression is not always maintained. In rare cases the legs may 
begin to atrophy soon after the affection of the hand. Muscular con- 
tractures from the action of antagonistic muscles, fibrillary twitching in 
the unaffected muscles, numbness and coldness in the regions of atrophy, 
and diminution and even loss of muscular reaction to faradic and galvanic 
currents are generally present in advanced cases. The reaction of degen- 



DISEASES OF THE NERVOUS SYSTEM. 991 

eration may be present in the very rapidly progressive lesions. The ex- 
citability of the nerve-trunks outlasts that of the muscles. The muscular 
weakness is proportionate and generally dependent upon the degree of 
atrophy. Sensation of heat, touch, and pain is not impaired. 

In another type of cases, described by Charcot as amyotrophic 
lateral sclerosis, a spastic paralysis precedes the wasting, but so far as I 
know this condition does not occur in children. 

In very rare cases in children the degenerative processes may affect 
the nuclei of the motor cranial nerves, both the upper and lower divisions 
of the motor tract being involved (Sachs). The symptoms in these cases 
bear a close resemblance to the progressive bulbar paralyses of adults, 
but are so rare that they need merely be referred to. 

Diagnosis. — The diagnosis is made on the slow, progressive wasting 
of muscles in the order described, on the gradual loss of power in the 
affected groups, on the fibrillary muscular contractions, on the diminution 
in the electrical reactions, on the absence of marked impairment of sensa- 
tion, and, in the great majority of cases, on the absence of hereditary or 
family influences. The rarity of the disease in early life is also of some 
value in the diagnosis. 

Prognosis. — The disease is progressive and may last for many years. 
It is invariably fatal, although there may be periods in which there is an 
apparent arrest of the process, but which is only temporary. 

Treatment. — The treatment is at best palliative and for the most part 
ineffective. Massage, electricity, anti-specific treatment if there is any 
evidence of a syphilitic taint, arsenic, and hypodermic injections of strych- 
nine, as recommended by Powers, may be tried. 

PROGRESSIVE NEURAL MUSCULAR ATROPHY. 

Progressive neural muscular atrophy is also known as the peroneal or 
leg type of progressive muscular atrophy. 

Etiology. — The disease is an hereditary or family affection, beginning in 
very early life in the cases reported by Sachs, and as late as twenty years 
in the case described by Charcot and Marie. Dubreuilh has reported a 
fatal and very typical case in a child in a family in which the mother and 
eleven children were similarly affected. 

Pathology. — The pathological conditions found in Dubreuilh's case 
showed chronic degenerative changes in the peripheral nerves, without 
lesions in the gray substance of the spinal cord, with the exception of a 
very slight increase in the glia of the column of Goll. The motor nerves 
of the hands and feet were especially involved. The muscles showed 
atrophy of the fibres ; some were degenerated and some were hypertro- 
phied. The transverse striations were diminished and the nuclei in- 
creased. According to Sachs, these muscular changes more closely resem- 
ble those which occur in the primary dystrophies than those which are 
dependent on changes in the spinal ganglia, and the slight lesions in the 



992 PEDIATRICS. 

cord are probably secondary to those in the peripheral nerves. As 
this class of cases is intermediate between those of central origin and the 
primary dystrophies, he considers the neural origin of the disease a theory 
to be accepted with reserve until verified by other cases. 

Symptoms. — The peroneal muscles and the muscles of the feet are the 
first to be affected, atrophy sets in, contractions of antagonistic muscles 
follow, and end in the production of club-foot, either pes equinus or pes 
equino-varus. Eventually the entire leg may atrophy. The upper ex- 
tremities and body are rarely affected until late in the disease, and the 
atrophy is not so marked as in the cases of central origin. In very rare 
instances the disease may begin in the hands. Fibrillary contractions and 
twitchings are present. The electrical reactions of both muscles and nerves 
are much diminished. The reflexes of the lower extremities are either lost 
or diminished. The sensations may be either normal or slightly altered ; 
the sense of pain is sometimes increased. Muscular weakness propor- 
tionate to the atrophy and deformity is present, and gives rise to a wad- 
dling gait, and especially to difficulty in going up-stairs. 

Diagnosis. — The diagnosis of progressive neural muscular atrophy is 
to be made from several similar conditions. 

From Progressive Muscular Atrophy of Central Origin. — This may be 
necessary in those cases in which atrophy of the lower extremities follows 
soon after the affection of the hands. The rarity of this condition in early 
life, the absence, as a rule, of hereditary influences, and the normal sen- 
sation are the only points in the differential diagnosis. Typical cases of 
either disease are readily distinguished by the onset and manner of pro- 
gression, but in atypical cases the differential diagnosis may not be pos- 
sible. 

From Poliomyelitis. — In poliomyelitis the sudden onset, retrogressive 
character of the atrophy, the absence of hereditary influences, and the 
absence rather than diminution of knee-jerks serve to distinguish the dis- 
ease from the slowly progressive hereditary paralysis which has just been 
described. The diagnosis from the subacute and chronic forms of polio- 
myelitis is often difficult until the progressive character of the disease 
becomes apparent. 

From Hereditary Ataxia. — The absence of ataxia, the abnormal electri- 
cal reactions, and the persistence of the reflexes in certain cases of pro- 
gressive neural muscular atrophy render the diagnosis from hereditary 
ataxia clear in most cases. 

From Chronic Multiple Neuritis. — In the muscular atrophy dependent 
upon neuritis, the greater prominence of pain and tenderness, the absence 
of hereditary or family influences, and the extreme rarity of the develop- 
ment of double club-foot generally enables us to distinguish neuritis from 
progressive neural muscular atrophy. 

Dejerine and Soltas have described a family disease of rare occurrence 
beginning early in life and resembling in many respects a progressive 



DISEASES OF THE NERVOUS SYSTEM. 993 

neural muscular atrophy. It is characterized by the symptoms of tabes 
dorsalis combined with progressive muscular atrophy involving the face 
and lips and by an interstitial hypertrophic neuritis extending into the 
dorsal columns of the cord. The condition is sometimes called progressive 
interstitial hypertrophic neuritis of infants. 

Prognosis. — The duration of the disease is very chronic, but there may 
be periods of arrest in its development. 

Treatment. — The disease is incurable. Much can be done by ortho- 
paedic surgery for the relief of deformities produced by the ' contractions. 
Massage and electricity are the main indications for treatment. 

PROGRESSIVE MUSCULAR DYSTROPHIES. 

Classification. — The group of diseases known as primary muscular dys- 
trophies, or primary myopathies, are represented by several forms, which 
differ from progressive muscular atrophy of central origin (Aran-Duchenne 
type) in that the lesions are primary in the muscles and are not dependent 
upon degenerative changes in the spinal cord. 

For the sake of convenience Erb has divided the muscular dystrophies 
into two large groups, which are still further subdivided into types de- 
pendent partly on pathological and partly upon clinical differences. This 
classification may be expressed as follows : 

I. Progressive Muscular Dystrophy of Infancy. 

A. Hypertrophic Form, in which the muscles are increased in 

size, and eventually become atrophic. 

a. With real hypertrophy of the muscle fibres. 

b. With false hypertrophy, the muscular fibres having un- 

dergone lipomatosis. 

B. Atrophic Form, in which there is no stage of hypertrophy. 

a. The Landouzy-Dejerine type, in which there is primary 

involvement of the face. 
6. An atrophic form without involvement of the facial muscles. 

II. Progressive Muscular Atrophy of Youth and Adult Life. This is also 

known as Erb's juvenile form. 

All these forms have certain points in common. There is a distinct 
hereditary influence or family association. The electrical reactions are 
diminished in all, but none show a typical reaction of degeneration. The 
reflexes diminish proportionately to the degree of muscular atrophy. 
As Sachs has pointed out, the chief distinction therefore between these 
clinical types are in reference to the distribution of the atrophy or hy- 
pertrophy. 

Etiology of the Muscular Dystrophies. — Heredity or association of 
cases in one family are the only etiological factors of any importance, so 
far as is known. This peculiarity serves as the most important point in 
the diagnosis of the dystrophies from progressive central muscular atro- 

63 



994 PEDIATRICS. 

phy, almost all cases of which, except Erb's infantile form, are free from 
hereditary influences. The disease is usually transmitted through the 
mother, who may not herself be affected, may run through as many as 
five generations, and generally attacks the males. The disease, as a rule, 
begins before puberty, rarely after the twentieth year. 

Pathology. — The chief histological changes in the muscular dystrophies 
consist in hypertrophy and atrophy of the muscular fibres, with pro- 
liferation of the nuclei, vacuolization and segmentation of the fibres. 
The hypertrophy of the muscle fibres appears to be an early process in 
all forms of muscular dystrophies, and is associated with lipomatosis and 
changes in the connective tissue. Atrophy of the muscle fibres is a later 
stage of the disease. No sharp distinction histologically can be drawn 
between the muscular lesions of the spinal amyotrophies and the muscular 
dystrophies, as hypertrophy of the muscle fibres may rarely occur in the 
spinal amyotrophies (Sachs). The dystrophies are, however, not asso- 
ciated with lesions of the central nervous system. 

Symptoms. — Pseudo-Hypertrophic Forms. — The earliest symptoms 
noticed are weakness of the muscles, a shuffling, clumsy gait, and 
awkwardness in the ordinary motions, especially in rising from the floor 
or climbing stairs. These symptoms generally precede any noticeable 
enlargement of the muscles. Gradually, however, the muscles of the 
calves increase in size and are hard and firm. The thighs are rarely 
hypertrophied. Atrophy of the thighs and of the deep muscles of the 
back, shoulder, and scapulae sets in. Late in the disease the atrophic 
process becomes general, affecting even the hypertrophied calves. The 
muscles of the face are not involved until in the very last stages. 

Children who are affected with this form of dystrophy learn to walk 
late, and assist themselves by leaning on the furniture or other objects in 
their path. When the child is placed on the floor on its back it has 
difficulty in getting up. It has to turn over on its face first, and then to 
aid the weakened muscles of the legs and trunk by means of the hands 
and arms, climbing up, as it Avere, upon itself by placing the hands upon 
the knees and then farther and farther up the thighs. Fibrillary con- 
tractions do not occur. The knee-jerks in some cases disappear as the 
disease advances. Sensation, as a rule, is normal. There is seldom 
any disturbance of the bladder or rectum. 

In the later stages of the disease contractions of the muscles occur, 
and in this way permanent distortions of the joints may result. The 
most common deformities are talipes equinus and flexion of the knees and 
hips. 

Lateral curvature occurs, or a permanent flexion of the spine from 
weakness of the erector spinse muscles may result so that the child sits 
bowed forward, or when kneeling on the hands and feet there is a 
saddle-shaped depression of the back. The electrical reactions show only 
quantitative changes. The reaction of degeneration is never present. 



DISEASES OF THE NERVOUS SYSTEM. 



995 



Atrophic Form. — This form is known as the Landouzy-Dejerine type. 
The muscles of the face and shoulder are primarily affected ; there is 
no hypertrophy except in very rare instances. The muscles of the fore- 
arm, hands, legs, and back remain unaffected. Westphal has described a 
case in which the face muscles were involved in an otherwise typical 
case of pseudo-hypertrophy. Other forms occur without involvement of 
the facial muscles. The Landouzy-Dejerine type, therefore, is not abso- 
lutely distinctive. I have reported a case of this affection in the first 
edition of this work. 



Fig. 208. 




Fig. 204. 



i m 



Pseudo-hypertrophic muscular paralysis, 
showing enlarged calves. 



Pseudohypertrophic muscular paralysis, shoving 
position assumed in rising from the floor. 



Brb's Juvenile Form. — The shoulder muscles are primarily affected. 
The disease begins in late childhood or early youth, and is characterized 
by progressive atrophy of the muscles of the shoulder, upper arm, 
pelvis, thigh, and back, the forearm and legs remaining normal. True or 
pseudo-hypertrophy may be associated with the atrophy in certain groups 
of muscles, notably in the deltoids, supra-spinati and infra-spinati 
muscles. 



996 PEDIATRICS. 

Diagnosis. — The differential diagnosis of the different forms of pro- 
gressive muscular dystrophies present many difficulties, and depend pri- 
marily upon the distribution of the lesions, as in all other respects they 
may be practically the same. 

The group differs from the spinal or central form, however, in the 
hereditary character of the affection, in the primary appearance and the 
distribution of the lesions, in the absence of fibrillary contractions, in the 
absence of marked electrical changes, and in their greater frequency in 
early life. 

The chief point in the diagnosis from progressive neural muscular 
atrophy is in the peculiar distribution of the atrophy in the latter affection 
to the muscles of the feet and to the peroneal group. 

Prognosis. — All forms of the muscular dystrophies are slowly pro- 
gressive and are incurable. The pseudo-hypertrophic type may render 
the patient a helpless cripple in two or three years. The other forms 
may last for ten, twenty, or thirty years, but the patient is very suscep- 
tible to intercurrent diseases. 

Treatment. — The treatment is very limited and does not differ from 
that of progressive central muscular atrophy described on page 991. 

Fig. 203 illustrates the hypertrophy of the calves which occurs in the 
pseudo-hypertrophic form of progressive muscular atrophy. Fig. 204 
represents a child with the same condition in the characteristic act of 
" climbing up on himself." 



DIVISION XVII. 

UNCLASSIFIED DISEASES. 



HAEMOPHILIA. 

In contradistinction to the hemorrhages of infectious origin which 
occur in the early weeks of life is that class of hemorrhages which can 
be classed under the term haemophilia. 

Haemophilia simply means a morbid condition characterized by a ten- 
dency to bleed spontaneously or from any insignificant wound. Indi- 
viduals who are liable to bleed in this way are designated as having 
a hemorrhagic diathesis. The disease is very uncommon in the early 
weeks of life, and usually occurs at a later period of development. It 
begins to be more frequent towards the end of the first year, and is 
apparently well established in the second year and later in childhood. 
It does not have a self-limited course, as is the case with the other form 
of hemorrhage. It is not infectious, and is not accompanied by fever. 
It may be for many years masked, and then may become manifest from 
some trivial cause, such as the extraction of a tooth. It is a dangerous 
disease, and death is very liable to occur from inability to control the 
hemorrhage. The condition is hereditary, being transmitted through the 
females to the males, but seldom occurring in the females, the proportion 
being one to eleven or thirteen (Osier). 

In addition to the hemorrhage which occurs in various parts in 
haemophilia Konig describes a condition of the joints which for a long 
time was supposed to be of gouty origin. This affection of the joints, 
like other haemophilic hemorrhages, occurs most commonly in boys and 
young men. The onset of the attack is sudden, and often without any 
history of trauma. The effusion into the joint is found to be of pure 
blood, and the quantity may be large. This effusion may be entirely 
absorbed spontaneously, or may occur later in the same joint or else- 
where. Shaw reports a case in which the recurring effusion into and 
about the joints was regularly preceded by a definite prodromal discomfort 
in the joint. After repeated attacks, chronic joint changes may ensue. 
There is no tendency to suppuration. The effusion sometimes occurs 
about, rather than in the joint. The disease is liable to be mistaken for, 
and is to be differentiated from, tumor albus and tuberculosis. Careful 

997 



998 PEDIATRICS. 

attention to personal and family history is the only safeguard in making a 
diagnosis of this disease, although we should always bear in mind the 
possibility of its presence in case of the affection of a joint of sudden 
onset in a young male and without history of severe traumatism. 

Treatment. — There is no treatment which has been found successful 
in these cases beyond the active local employment of styptics and com- 
pression. Gelatin and suprarenal extract should be tried (page 321). 

PURPURA. 

Purpura is a term applied to certain conditions in which there are 
hemorrhages into the skin or mucous membranes. These hemorrhages 
may be of various sizes. When small, they are called petechias ; when 
larger, they are called ecchymoses. There is no proof that purpura is a 
disease of the blood. Its etiology is very obscure, and although this con- 
dition has been divided into various forms, such as purpura simplex and 
purpura hemorrhagica, it is doubtful whether these are not all microbic in 
their origin and simply represent different degrees of infection. 

In the more simple forms of purpura the hemorrhages are only in the 
skin, while in the more severe affection the mucous membranes of the 
mouth and gastro-enteric tract are usually involved. 

Not only does purpura occur in what may be called primary forms, 
but this purpuric condition may also be secondary to a number of dis- 
eases, especially those of an exhausting nature. Thus, I have seen it in 
the more severe and later stages of infantile atrophy, in which the hem- 
orrhages may cover almost the entire front of the body. It may also be 
a symptom in the more severe cases of measles, scarlet fever, varicella, 
variola, diphtheria, and in the course of a prolonged rheumatic attack. 

In an infant who died of infantile atrophy at the Infants' Hospital the skin of the 
extremities showed numerous ecchymoses of various sizes and of a dark red and pur- 
ple color. On the thorax on both sides above the nipples were two large ecchymoses, 
and there were smaller ecchymoses all over the rest of the trunk. On post-mortem 
examination nothing abnormal was found except a slight atelectasis of the lower lobes 
of both lungs, with pleuritic adhesions at the base of the right lung and slight granular 
degeneration of the heart, liver, and kidneys, with hyperplasia of the mesenteric lymph- 
nodes. 

Purpura Simplex. — In the simple forms of purpura the disease in 
children is often mild, and is accompanied by a loss of appetite, slight 
anaemia, a slight degree of fever, and the appearance of petechia? in va- 
rious parts of the skin. The prognosis is good, and the duration of these 
attacks is usually from one to two weeks. They are at times associated 
with pains located in various places. 

Purpura Rheumatica. — The form which has been called purpura 
rheumatica (peliosis rheumatica; Schonlein's disease) probably has no con- 
nection with rheumatism beyond the possibility of their both being mi- 
crobic, and merely simulates rheumatic arthritis from the fact that it affects 



UNCLASSIFIED DISEASES. 999 

the joints. The diagnosis is made by the characteristic association of mul- 
tiple arthritis with purpura and urticaria. 

Henoch's Purpura. — Closely simulating and probably representing 
purpura rheumatica, except that the gastro-enteric symptoms are more 
prominent, is a form which has been called Henoch's purpura. It occurs 
especially in children between the ages of three and nine years. Its direct 
cause is not known, although it usually occurs among children who have 
had bad hygienic surroundings and have been ill cared for. 

Symptoms. — The symptoms are more or less malaise, and pains not 
especially localized, but chiefly occurring in the extremities and back, 
sometimes accompanied by slight oedema of the part affected. These 
early symptoms of pain occur in one or more joints, usually on the outer 
sides, and sometimes there are swelling and redness simulating articular 
rheumatism. In this stage there may be a sudden rise of temperature. 
Accompanying these symptoms there may be a few purpuric spots, but, 
as a rule, there is a period of several days between the appearance of the 
pains in the joints and the purpuric appearances on the skin. The pur- 
puric spots may coalesce, and thus form ecchymoses of various sizes 
and colors. They are very apt to begin on the lower leg and spread up 
to the thighs, genitals, and body. Somewhat later intestinal symptoms 
develop. While the purpura is spreading there is severe colic, and the 
pain is very intractable to treatment. The abdomen is retracted and 
tender. There is obstinate vomiting. The pulse is weak, and the face 
has an anxious expression. There is more or less diarrhoea, which usually 
occurs at the end of an attack of colic. The colic and vomiting some- 
times last for one or two days. There may be a little blood in the vomitus 
and in the movements. The vomiting then diminishes, the colic ceases, 
and later the diarrhoea stops, the pain in the joints passes away, the pur- 
puric spots gradually fade and disappear, and the child, although left in an 
exhausted condition, is otherwise well. 

There are very apt to be relapses, which may appear within a few 
days or not for several weeks. 

These are the symptoms of a typical case ; but there are many varia- 
tions. As a rule, the younger the child the more typical is the case. 
Sometimes the purpuric spots closely simulate urticaria. They may occur, 
although rarely, in the mouth. They sometimes simulate the lesions of 
erythema nodosum. The attacks of colic have a paroxysmal character. 
There may be swelling of the joints. 

The disease is rarely fatal unless it is complicated by some such dis- 
ease as nephritis or endocarditis. The treatment is purely symptomatic. 

Purpura Hsemorrhagica. — The most severe form of purpura which 
occurs is that which is called purpura haemorrhagica (morbus maculosus 
Werlhofii). The hemorrhages in this form are from the mucous mem- 
branes as well as into the skin. The disease begins with debility. A few 
days later purpuric spots appear on the skin, and subsequently haema- 



1000 PEDIATRICS. 

turia and haemoptysis occur, from which excessive anaemia may result. 
There is usually slight fever. When recovery takes place it is gradual, 
usually occupying two or three weeks. 

The prognosis is unfavorable in early life, as death may take place from 
the exhaustion following loss of blood or from hemorrhage into the brain. 
The diagnosis of purpura haemorrhagica is to be made from scorbutus by 
the general history of the case, and by the absence, if teeth are present, 
of stomatitis ulcerosa. 

Purpura Fulminans. — A very malignant purpura haemorrhagica may 
occur, sometimes proving fatal within twenty-four hours. This form of 
purpura is usually spoken of as purpura fulminans. It is most commonly 
met with in infants and in very young children, and is characterized by 
cutaneous hemorrhages which develop with great rapidity, death some- 
times taking place before there has been any hemorrhage from the mu- 
cous membranes. I have met with the reports of only seven or eight 
cases of this malignant form of purpura. 

The following case represents this severe form of purpura : 

An infant, seven months old, had always been perfectly well, and was being 
nursed by its mother, who was a healthy, strong woman, and had a number of other 
healthy children. The father was also a remarkably strong and well man. This 
infant, without noticeable previous symptoms, suddenly developed this severe form of 
purpura. Large ecchymoses appeared upon the buttocks and on the trunk, and the infant 
rapidly failed in strength, and died in twenty-four hours. There was no hemorrhage 
from the mucous membranes. 



STATUS LYMPHATICUS (Lymphatism). 

Status lymphaticus is a term which has been given to a condition 
which occurs chiefly in childhood, and is characterized by a hyperplastic 
condition of the lymph-tissues and lymphoid bone-marrow throughout the 
body. 

Etiology. — The cause of this condition is not known. It has been 
found in connection with rhachitis and hypoplasia of the heart and aorta. 
Unhygienic surroundings tend especially to the production of the disease, 
and heredity seems to be a factor in the etiology. 

Pathology. — The lymphatic tissues are generally hyperplastic, but the 
proliferation is especially marked in the pharyngeal, thoracic, and abdomi- 
nal groups of lymph-nodes. The enlargement of the spleen is moderate 
and its tissues are soft and hyperaemic. The thymus is large and may be 
ten centimetres in length. Hypoplasia of the bone-marrow, heart, aorta, 
and thyroid gland is present. 

Symptoms. — The symptoms of status lymphaticus are those which may 
occur in any case of lowered vitality, but distinct clinical features do not 
exist. 

Diagnosis. — The diagnosis is not easily made. It depends upon the 



UNCLASSIFIED DISEASES. 1001 

recognition of the general lymphatic enlargement and the exclusion of 
other causes, such as tuberculosis and leukaemia. 

Prognosis. — The special tendency to sudden death which exists in this 
condition must be borne in mind. The vitality of the child is distinctly 
lowered, and it is especially susceptible to the toxic actions of the acute 
infectious diseases. At the same time there is a tendency to outgrow this 
condition as puberty approaches, so that with careful management the 
prognosis may become favorable. 

Treatment. — The treatment is essentially symptomatic, and consists 
chiefly in the regulation of the food and hygiene of the child. 

MUSCULAR, RHEUMATISM (Myalgia). 

Muscular rheumatism is an affection characterized by pain and stiff- 
ness in certain groups of muscles. It may be acute or chronic. 

Etiology. — The disease is usually seen in children between the ages 
of five and fifteen, and generally follows exposure to cold or dampness 
and to bad hygienic surroundings. It has been held by Leube, Peltessohn, 
and others to be due to infectious micro-organisms, but there is as yet no 
proof of this. 

Symptoms. — Pain on movement and tenderness and stiffness of certain 
muscles are the typical symptoms. Fever is rarely present. The pain is 
at times quite severe, slight movements of the muscles bringing on sharp 
exacerbations. Certain names have been given according to the group of 
muscles affected, such as cervicodynia, or acute torticollis, when the process 
is located in the muscles of the neck ; pleurodynia when in the intercostal 
muscles ; lumbago Avhen in the lumbar muscles ; cephalodynia when in 
the muscles of the head ; scapulodynia and omodynia when in the mus- 
cles of the shoulder. 

The disease may be acute or chronic, the acute cases recovering in 
a few days. The chronic cases may persist for weeks, often leading to 
increase in the connective tissue, producing muscular stiffness and con- 
tractures. 

Diagnosis. — The diagnosis is to be made from pleurisy by the absence 
of physical signs and by the pain and muscular tenderness. It is distin- 
guished also from neuritis, in which the tenderness is along the course of 
the nerves and in which massage is not efficient. 

Treatment. — Drugs are of less use than hot air and massage. Heat 
may be applied by means of a hot flat-iron rubbed on the affected part 
protected by a piece of thick flannel. Massage is especially to be recom- 
mended. Electricity is of service in chronic cases. Phenacetine and the 
salicylates are the drugs which are indicated ; they should be used with 
caution if they seem to benefit the especial case, and should not be em- 
ployed as a routine treatment. The lithia waters should be given freely. 

The following case is illustrative of acute torticollis dependent upon 
acute muscular rheumatism : 



1002 



PEDIATRICS. 



The boy was five years old. Since he was three years old he had been subject 
to attacks of torticollis, apparently of rheumatic origin. He was brought into the hos- 
pital in one of these attacks. His temperature was somewhat raised, and he had a 
slight loss of appetite, but otherwise was perfectly well, and did not suffer any pain 
except when his neck was touched. The head was drawn rigidly back. These 
paroxysmal attacks usually lasted two or three days, when they passed off as sud- 
denly as they came. The last attack which he had was one year before. 

Pig. 205. 





00 





M'&^L 



Acute rheumatic torticollis. Fifth day of attack. 

On the following day the stiffness and the pain in the neck passed off, and the head 
resumed its normal position. Various drugs had been given in these attacks, but 
none with any especial benefit except salicylate of sodium, which seemed to control the 
pain. 

I have also had under my care a little boy, about four years of age, who was 
attacked with fever, pain in the region of the spine, and spasm along the entire length 
of the spinal column. There was no pain or tenderness anywhere except over the verte- 
bral column, and these symptoms were not so marked in the cervical region as lower 
down. The child had no mental disturbance, but for a number of days was in a con- 
dition of continued opisthotonos from the hips upward, so that he had to be kept in a 
reclining chair with pillows under his arched back. The normal functions of the 
bladder and intestine were not interfered with. The pulse was rapid, the temperature 
was moderately raised, and the respirations were normal. The appetite was lessened. 
He remained in this condition for about a week, when the spasm of the back began to 
disappear. The muscles relaxed for a short time and then stiffened again. Finally 
complete relaxation took place, and the child recovered entirely. The attack was acute 
in its onset, and did not follow any injury. The treatment was with bromide of potas- 
sium, 0.3 gramme (5 grains) three or four times in the twenty-four hours. 



UNCLASSIFIED DISEASES. 1003 

ARTHRITIS DEFORMANS. 

Arthritis deformans, while generally a disease of adult life, may occur 
in children, usually after the age of six, and may present the same char- 
acteristics as in later life. 

There is, however, in young children a special variety of the disease, 
which has been described by Still. This form generally occurs before the 
second dentition, and is more frequent in girls than in boys. There is a 
general enlargement of the joints associated with swelling of the spleen 
and lymph-nodes. The onset is sometimes acute, with fever and even 
chills. The joints gradually become stiffened and enlarged, due to a 
proliferation of the soft tissues rather than of a bony enlargement. The 
limitation of motion and muscular- wasting about the joints is often 
pronounced, but there is no bony grating. There may be profuse sweat- 
ing. The blood shows only a secondary anaemia. 

Prognosis. — The disease is incurable, and progresses slowly for many 
years. At times an arrest of the disease occurs. 

Treatment. — The treatment by drugs is useless, except so far as to 
control the symptoms. Arsenic and iron are useful for the anaemia. Food 
and fresh air, hydrotherapy, massage, and hot-air are the principal indi- 
cations for treatment. 

CHRONIC RHEUMATISM. 

Etiology. — Chronic rheumatism may occur in children as a result of 
acute rheumatic fever, but is more likely to come on insidiously in con- 
nection with unhealthy surroundings, poor food, and undue exposure to 
cold and dampness. 

Pathology. — The pathological lesions are represented by injection of 
the synovial membranes, thickening of the capsules and ligaments of the 
joints and of the neighboring tendon sheaths, and erosions of the car- 
tilages if the process has been of long duration. 

Symptoms. — Pain and stiffness in the joints with a susceptibility to 
exacerbations, during which swelling and tenderness without redness set 
in, are the chief symptoms. Ankylosis of the joints may occur event- 
ually. Debility and anaemia appear as secondary conditions. The dis- 
ease is usually persistent and slowly progressive, but does not directly 
shorten life. 

Treatment. — Avoidance of cold weather and dampness is desirable. 
General hygiene, good food, massage, and the treatment with hot air are 
of great benefit. Many cases will improve under treatment at various 
hot springs. 

DIABETES INSIPIDUS. 

Diabetes insipidus is a disease characterized by the passage of large 
quantities of urine of very low specific gravity, free from sugar and other 
abnormal elements, and often with a considerable increase in the total 
amount of solids. 



1004 PEDIATRICS. 

Etiology. — The cause of the disease is not known. It is probably in 
the nature of a neurosis, causing a vasomotor disturbance of the renal 
vessels with continuous congestion of the kidney. In a series of eighty-five 
cases collected by Strauss, nine were under five years and twelve between 
five and ten years. In seventy cases reported by Roberts, twenty-two 
occurred before ten years. It may be congenital or begin in infancy, but 
is an exceedingly rare disease. In certain cases there is a strong heredi- 
tary tendency. It has been recorded in the members of four generations 
of one family (Weil). 

Pathology. — Enlargement and congestion of the kidneys, hypertrophy 
of the bladder, dilatation of the ureters and pelves of the kidney, and 
inconstant lesions of the nervous system have been noted. 

Symptoms. — The symptoms are directed especially to the urine, Avhich 
is passed in very large quantities ; in one case of Trousseau's, in an adult, 
amounting to twenty-eight quarts a day. There is a very low specific 
gravity, varying from 1001 to 1005 or 1007. Glucose is never present, but 
inosite (muscle-sugar) has at times been noted. Albumin and casts are of 
only rare occurrence. The total solids are normal or in many cases 
greatly increased. 

Intense thirst, a dry skin, disturbance in the surface circulation, and 
general nervous symptoms are present, but emaciation is not apt to occur 
as in diabetes mellitus. The appetite is good. Often the general health 
is not interfered with, and the disease may last for a period of years. 

Diagnosis. — The condition is to be distinguished from nervous or hys- 
terical polyuria, which is of temporary duration and is associated Avith 
other hysterical symptoms. 

It is differentiated from diabetes mellitus by the absence in the urine 
of glucose or grape-sugar. 

Chronic interstitial nephritis may be excluded from the diagnosis by 
the presence of albumin and casts and the low percentage of solids 
eliminated, together with the clinical symptom of chronic nephritis. 

Prognosis. — Occasionally spontaneous recovery may take place, but 
oftener the disease is likely to remain chronic and the child to die of some 
intercurrent affection. 

Treatment. — A nitrogenous diet with small amounts of carbohydrates 
and only a moderate restriction of fluids are indicated. Drugs do not 
control the disease, although many have been recommended, the most 
prominent of these being belladonna in increasing doses up to its physio- 
logical limits and opium, continued for many months. Arsenic and the 
bromides may also be tried, but their beneficial action is doubtful. 

DIABETES MELLITUS. 
Diabetes mellitus is a disease characterized by the excretion in the 
urine of glucose or grape-sugar in considerable quantities and for a long 
period. It is sometimes acute, but is generally chronic. It is to be dis- 



UNCLASSIFIED DISEASES. 1005 

tinguished from the condition known as temporary glycosuria, in which 
sugar is present in the urine for a short time only, as after certain acute 
infectious diseases, injuries to the head, or from absorption of some toxic 
substance. There is still another variety of glycosuria which is spoken 
of as temporary alimentary glycosuria. In this form sugar appears in the 
urine after the ingestion of large quantities of saccharine foods, and dis- 
appears at once upon reducing the sugar in the diet. 

Etiology. — Diabetes mellitus may occur in infancy or at any period 
of childhood. It is very common among the Jews, and is infrequent 
among the negroes. 

It occurs more frequently in girls than in boys. In Stern's analysis 
of one hundred and seventeen cases in children, six were under one year 
of age. 

In many cases an hereditary influence seems to be a factor in the 
etiology ; in others a severe nervous shock, such as may come from sud- 
den fright or great grief, may be an exciting cause. Trousseau states that 
the children of tubercular parents are particularly susceptible to diabetes. 
Injuries to the head, especially if the floor of the fourth ventricle is in- 
volved, may cause the appearance of sugar in the urine. Occasionally 
temporary glycosuria may arise from the administration of antitoxin, 
and it may appear shortly before death in cases of chronic diffuse and 
subacute glomerular nephritis. 

Pancreatic diabetes follows the removal of the pancreas in dogs, and 
lesions in the pancreas are found in about half of the cases of diabetes 
mellitus ; the appearance of sugar in the urine in these cases is supposed 
to be due to the absence of the glycolytic ferment in the pancreatic 
juice. 

Phloridzin and a few other substances may cause diabetes mellitus by 
destroying the power of the renal epithelium to keep back the sugar. 

Faulty metabolism and defective assimilation of the glucose probably 
underlie most cases of diabetes, but much is to be learned as to the real 
nature of the disease. 

Pathology. — Lesions in the medulla from tumors or scleroses have 
been found, and glycogen has been found in the spinal cord. There may 
be a secondary multiple neuritis. The blood may contain as much as 
0.4 per cent, of sugar instead of the normal 0.15 per cent. The plasma 
is fatty and the polynuclear leucocytes contain glycogen. Tuberculosis 
of the lungs is not uncommon, and may follow an acute broncho- or 
pneumococcus lobar pneumonia. The liver is enlarged and fatty. 
Lesions of the pancreas, generally atrophy, are present in nearly fifty per 
cent, of the cases. The kidneys usually show evidence of diffuse nephritis 
with fatty degeneration. 

Symptoms. — The symptoms in the temporary form of diabetes may be 
slight, and the sugar is discovered only in the routine examination of the 
urine. There may be an increased flow of urine and a craving for sweet 



1006 PEDIATRICS. 

articles of diet. The appetite is good. The thirst may be increased. 
Indigestion is not uncommon. 

In true diabetes the symptoms are much more severe. Great thirst, 
excessive appetite, and polyuria are the striking symptoms. There is pro- 
gressive and extreme emaciation, the skin is harsh and dry ; sweating is 
rare. Constipation is usually present. The flow of saliva is abundant. 
The genitals are at times irritated by the urine. 

Urine. — The quantity of urine is greatly increased, generally averaging 
between 3000 to 5000 c.c. (100 to 166 ounces), although it may be much 
more or be less than normal. The urine is pale, strongly acid, and of 
high specific gravity, the degree depending upon the amount of sugar 
present. The solids are relatively diminished but absolutely increased in 
amount. Glucose or sugar is always present, and varies from a mere 
trace to 8, 10, or 12 per cent., and the total quantity in twenty-four hours 
varies from 20 to 60 grammes (f to 2 ounces), often amounting to sev- 
eral hundred grammes. There is usually the slightest possible trace of 
albumin and a few casts, indicative of a mild, active hyperemia of the 
kidneys. 

Diabetic Coma. — Diabetes mellitus frequently ends in coma, this pre- 
sumably being brought about by some toxic substance in the blood. This 
complication is especially common in children. It is at times precipitated 
by sudden changes in diet, especially when the patient is put upon a rigid, 
nitrogenous diet, but it may also follow many other conditions, such as 
intercurrent acute diseases and operations. 

Acetone and diacetic acid are found in the urine in advanced cases of 
diabetes, and are always of serious prognosis, as they indicate a threat- 
ened state of coma, but they may be present for months before any 
symptoms of coma appear, and may even disappear as the patient im- 
proves under treatment. Acetone and diacetic acid are probably rarely T 
if ever, present in cases of temporary glycosuria. 

The advent of coma may be suspected by the appearance of mental 
apathy, nausea, vomiting, and epigastric pain. The breath has a peculiar 
odor of acetone. Convulsions rarely occur, which is a point of con- 
siderable value in excluding a coma due to uraemia. Bremer's blood-test 
with methylene-blue or congo-red will also aid in determining the nature 
of the coma, as a positive reaction will almost always be obtained, even 
in the early stages of diabetes mellitus. 

Complications. — Boils, furuncles, eczema, and prurigo are common 
complications. Gangrene may occur. Pneumococcus lobar pneumonia, 
broncho-pneumonia, and especially tuberculosis of the lungs, are likely to 
occur and prove fatal. 

Peripheral neuritis with pain and paralysis may occur, sometimes 
with symptoms suggestive of tabes. The disease may be manifested by 
paralysis, either the arms or legs being affected, the form being diplegic. 
Absence of the knee-jerk is not uncommon, and is probably due h> 



UNCLASSIFIED DISEASES. 1007 

neuritis. Mental depression or extreme restlessness or nervousness often 
develops. 

Cataract, retinitis, sudden amaurosis, ocular paralysis, and atrophy of 
the optic nerves occasionally occur. Otitis media or a mastoiditis may 
appear suddenly. (Edema is a common symptom, and does not always 
depend on disease of the heart or kidney. 

Diagnosis. — It is important to distinguish between diabetes mellitus 
and temporary glycosuria. This is sometimes difficult. In the former, 
however, sugar is present in every specimen of urine passed, irrespective 
of the time of day. In temporary alimentary glycosuria the urine in the 
early morning, after ten or twelve hours of fasting, is generally free from 
sugar, or only traces are present, whereas after a meal considerable 
quantities of sugar are eliminated. A rigid diet, free from carbohydrates, 
will also help to make the distinction clear, as the quantity of sugar in 
true diabetes mellitus is reduced only with difficulty and often cannot be 
markedly influenced. 

From other forms of polyuria the diagnosis is made clear by the 
presence of sugar as determined by Fehling's test. 

Bremer's blood-test with congo-recl is a valuable aid in differentiating 
true diabetes mellitus from phloridzin diabetes. 

Prognosis. — The disease runs a much more rapid course in children 
than in adults. In Stern's one hundred and seventeen cases the shortest 
duration was two days. In seven cases death took place within a month. 
He mentions one case of a child whose urine contained sugar at birth, 
and who recovered in eight months. In children the disease is almost 
universally fatal, but C. Sterns, in a series of seventy-seven cases in chil- 
dren, found that fourteen recovered, and in one hundred and eight cases, 
also children, reported by Wegeli, only sixty-four terminated fatally. 

The younger the child the more grave is the prognosis. 

Treatment. — The treatment of diabetes mellitus consists practically in 
the regulation of the diet, the endeavor being to limit the ingestion of 
carbohydrates. The diet should consist, so far as possible, of meat, fish, 
eggs, green vegetables, salads, and nuts. Too great a quantity of meat 
should be avoided, as excessive nitrogenous food as well as carbohydrates- 
will increase the percentage of sugar in the urine. 

It is well to test the patient's capacity to assimilate sugar by quanti- 
tating the sugar passed in twenty-four hours when on ordinary diet, and 
then to institute a strict diet for several days, the sugar being estimated 
daily. The results will give us indications as to whether to push the re- 
stricted diet or to allow more freedom in the choice of foods. When 
coma is threatened, or when the reaction for diacetic acid with ferric 
chloride is positive, carbohydrates should be added to the diet for a 
time. 

If under a strict diet the sugar disappears, the diet can gradually and 
cautiously be increased, but at intervals of a few months diabetics should 



1008 PEDIATRICS. 

return to their restricted diet for a few weeks as a matter of precaution 
and to increase their power of assimilation of the carbohydrates. 

The following articles represent as varied a diet list for diabetics as is 
compatible with conservative treatment : oxtail soup, bouillon, and clear 
soups made from meats ; lemonade, chocolate, and cocoa, with saccharin 
for sweetening ; soda-water and charged waters. 

Fresh fish of all sorts, with oysters in season, poultry, game, eggs, 
butter, buttermilk, and cream cheese, lettuce, tomatoes, spinach, chicory, 
sorrel, radishes, asparagus, watercress, cucumbers, celery, and endives are 
permissible. 

Of the fruits, lemons, oranges, currants, plums, cherries, pears, apples, 
melons, raspberries, and strawberries may be taken in moderation if a 
strict diet is not being adhered to. Nuts may be given if they do not dis- 
turb digestion. 

Among the articles especially to be avoided are thick soups, liver, all 
forms of bread, and all dishes prepared with flour or sugar. Vegetables 
growing under ground are to be avoided. Beers, wines, and alcoholic 
drinks should not be used. 

Most of the gluten breads and diabetic flours in the markets are adul- 
terated with flour, and cannot be relied upon. 

A mixture of practically sugar-free milk can be obtained at the various 
milk-laboratories, and will probably in the future prove to be of much use 
in the dietetic treatment of diabetes, especially in infancy. 

But little is to be expected in the treatment of diabetes from the use 
of drugs, except so far as to allay symptoms. Opium, usually given in the 
form of codeia, is quite generally used, but I have not myself seen striking 
results from its administration. 

HYPERTROPHIC PULMONARY OSTEO-ARTHROPATHY. 
Hypertrophic pulmonary osteo-arthropathy is a condition character- 
ized by enlargement of the hands and feet and the ends of the long bones. 
The terminal phalanges are increased both in the transverse and longi- 
tudinal curves, and the nails show a tendency to be curved over the ends 
of the phalanges. Unlike acromegaly, the bones of the skull and face 
are not involved. The condition was first described by Bamberger, and 
the name was given to it by Marie. The condition is chronic, and is 
usually associated with some disease of the lung of considerable dura- 
tion ; it may be a sarcoma, chronic bronchitis, tuberculosis, syphilis, or 
empyema. The disease occurs usually in adults, but occasionally in 
children. I recently reported a case in a child of four years. 



INDEX. 



Abdomen, anatomy and relations of the, 57 ; 

at term, 33 
Abscess, cerebral, 949 ; of the liver, 836 ; of 
the lung, 707 ; peritonsillar, 654 ; psoas, 
■±29 ; retropharyngeal, 656 
Acardia, 721 
Aoarus scabiei, 355 
Acetone in diabetes mellitus, 1006 
Achondroplasia, 342 
Achorion Schoenleinii, 360 
Acidophilic, 875 

Acquired disease, definition of, 19 
Acute circumscribed oedema, 379 

fatty degeneration of the new-born, 312 
fermental diarrhoea, 805 
infectious osteomyelitis, 51 
miliary tuberculosis of the lungs, 393 
nervous diarrhoea, 796 
nervous vomiting, 774 
torticollis, 1001 

yellow atrophy of the liver, 835 
Addison's disease, 908 
adenitis, simple acute, 897 ; simple chronic, 

898 
Adenoid growths. 645 
Adolescence, albuminuria of, 848 
Adrenal gland, diseases of the, 908 
xEstivo-autumnal parasite, 483, 484 
Age, determination of, in premature infants, 

257 
Agenesis corticalis, 931, 951 
Albuminuria of adolescence, 848 

physiological, 847 
Albumin water, preparation of, 791 
Alopecia areata, 361 ; in syphilis, 525 
Amaurosis in scarlet fever, 573 
Amnesia, temporary, 937 
Amoebic ileo-colitis, 501, 820 
Amyloid degeneration of the heart, 734 

infiltration of the kidney, 859 ; of the 
liver, 837 
Amyotrophic lateral sclerosis, 991 
Amyotrophies, 990 

Anaemia, primary or pernicious, 890 ; in- 
fantum pseudo-leuksemica, 887 ; second- 
ary, 894 ; splenica, 887 ; splenica infet- 
tiva, 887 ; von Jaksch, 887 
Anatomy of infants and childi^en vide In- 
fant at term, and Normal development ; 
topographical, 88 
Anencephalia, 290 
Aneurism, 720 ; intra-cranial, 978 
Angio-neurotic oedema, 379, 943 
Animal parasites, 829 ; ascaris lumbricoides, 
831 ; oxyuris vermicularis, 829 ; taenia 
saginata or mediocanellata, 832 ; taenia 
solium, 832 



Antitoxin, dose of, 471 ; immunizing dose 
of, 469 ; technique of injection of, 473 ; 
in treatment of diphtheria, 471 

Anuria, 847 

Anus, imperforate, 307 ; in syphilis, 827 

Anopheles, genus, in malaria, 481 ; quadri- 
maculatus, 482 

Aorta, transpositions of, 721 

Aortic insufficiency, 743 ; stenosis, 744 

Aortic orifice, lesions of the, in congenital 
disease, 726 

Aphasia, organic, 938 ; temporary, 937 

Appendicitis, 815; catarrhal, 816; chronic, 
818; diagnosis, 819; etiology, 815; ob- 
literative, 818; pathology, 815; prog- 
nosis, 819; simple, 816; symptoms, 816; 
treatment, 819; ulcerative, 816; with 
general suppurative peritonitis, 817 ; with 
periappendicular peritonitis, 817 ; with 
septicaemia, 818 

Aran-Duchenne type of progressive muscu- 
lar atrophy, 989 

Arrested psychical development, 938 

Arteries, transposition of the large, 726 

Arteritis umbilicalis, 301 

Arthritis of infants, 511 ; deformans, 1003 

Ascaris lumbricoides, 831 

Ascending colon, relations of, 69 

Ascites. ( Vide symptoms of the especial dis- 
eases. ) 

Asphyxia in the new-born, 312 

Aspiration pneumonia, 691 

Asthma, bronchial, 673 ; dyspepticum, 946 ; 
false, 674 

Ataxia, hereditary, 988 ; locomotor, 989 

Atelectasis, 705 ; acquired, 706 ; in broncho- 
pneumonia, 694 ; congenital, 705 
| Athetosis, 954, 976 
j Athrepsia, 348 
J Athyrea, 901, 905 

Atomization, 655 

Atropine, doses of, in children, 470 

Attenuants of cow's milk, 179 

Aura, in grand mal, 926 



Babcock fat-tester, 124, 191 
Bacillus, Brieger's, 177 ; of Eberth, 447 ; of 
Friedlander^ 691 ; comma, of Koch, 505 ; 
Klebs-Loeffler, 459 ; lactis aerogenes, 87, 
177, 182; of Pfeiffer, 476; of tetanus, 
496 ; tubercle, 381 
Bacteriology of cow's milk, 180 
Balanitis, 870 
Barley-gruel, 239 

-jelly, preparation of, 239 

-water, preparation of, 239 

64 1009 



1010 



INDEX. 



Basophiles, 874, 878 

Basophilic, 875 

Bath, temperature of, 96 

Bathing of infants, 96 ; in typhoid fever, 
455 

Bednar's aphthae, 622 

Beri-beri, 985 

Bile at term, 38 ; in infancy and childhood, 
83 

Bile-ducts, congenital obliteration of the, 
308 

Biliary calculi, 837 

Birth-palsies, 951 

Bladder at term, 36 ; in childhood, 58 ; dis- 
eases of the, 865 ; reflex symptoms of the, 
948 ; tuberculosis of the, 431 

Blood, at term, 38 ; amount at birth, 876 ; 
average number of corpuscles at different 
ages, 878 ; color, 876 ; development of 
the, 56 ; diseases of the, 874 ; haemo- 
globin, 876, 880 ; in abnormal condi- 
tions, 879 ; in chlorosis, 893 ; in infancy, 
874 ; in leukaemia, 884 ; in normal con- 
ditions, 875 ; in pernicious anaemia, 890 ; 
in pseudo-leukaemia, 888 ; in secondary 
anaemia, 895 ; nomenclature of the, 874 ; 
percentages of various leucocytes in the, 
879 ; reaction, 876 ; red corpuscles, 877, 
880; specific gravity, 876, 880. (Vide, 
also, symptoms and diagnosis of the espe- 
cial disease. ) 

Blood-corpuscles, description of different va- 
rieties of, 874 ; red, 877, 880. ( Vide, also, 
Blood. ) 

Blood-vessels, diseases of the, 720 

Bone, lesions of the, in cretinism, 901 ; in 
rhachitis, 329 ; in syphilis, 523, 528, 536 

Bone-marrow, 81 ; at term, 37 

Boracic acid, strength of, in local applica- 
tions, 869 

Bow-legs, 111 

Brain, at term, 29 ; development of the, 47 ; 
in cerebro-spinal meningitis, 434 ; syph- 
ilis of the, 978, 980 ; tuberculosis of the, 
406, 978 

Branchial fistula, 296, 767 

Brandy, dose of, 456 

Breast-pump, 119 

Breck's feeder for premature infants, 273 

Bremer's blood-test in diabetes mellitus, 
1006 

Brieger's bacillus, 87, 177 

Bright's disease, acute, 853 ; chronic, 857 

Broadbent's sign, 765 

Bromides, doses of, in epilepsy, 929 

Bronchi, diseases of the, 665 

Bronchial asthma, 673 

Bronchiolitis exudativa of Curschmann, 673 

Bronchitis, acute, 666 ; capillary, 697 ; 
chronic, 671 ; fibrinous, 672 ; unusual 
forms of, 669 

Bronchocele, 899 

Broncho-pneumonia, acute, 691 ; acute tu- 
bercular, 394 ; aspiration, 691 ; chronic, 
704 ; definition of, 675 ; diagnosis, 700 ; 
etiology, 691 ; pathology, 692 ; physical 
signs in, 699 ; primary forms in, 691 ; 
prognosis, 700; secondary forms in, 691 ; 
symptoms, 696 ; terminations and com- 
plications in, 699 ; treatment, 701 



Brooder for premature infants, 267 

Brown atrophy of the heart, 734 

Bruit de diable, 893 

Buhl's disease in the new-born, 312 

Bulbar paralysis, 985 

Bursa pharyngea at term, 28 

O. 

Cachexia strumipriva, 901 

Caecum and ascending colon, relations of, 69 

Calcareous degeneration of the heart, 734 

Calculi, biliary, 837 

Calomel, dose of, 796 

Canal of Nuck, encysted hydrocele of, 306 

Cancrum oris, 629 

Capillary bronchitis, 697 

Caput succedaneum, 286 

Carcinoma of the brain, 978. ( Vide, also s 
Tumors. ) 

Cardiac disease, vide Heart ; dilatation, 732 ■ 
hypertrophy, 731 

Cascara sagrada, dose of, 805 

Caseinogen, 178; definition of, 223 

Castor oil, dose of, 796 

Catalepsy, 935 

Catarrhal fever, 476 

Cephalhaematoma, 287 

Cephalodynia, 1001 

Cereals in laboratory feeding, 202 ; direc- 
tions for making, 239, 240 

Cerebral abscess, 949 

meningitis, table of, diagnosis of, 415 

palsies, infantile, 950 

paralysis, 950 

sinus, thrombosis of the, 975 

syphilis, 978, 980 

Cerebro-spinal fluid in cerebro-spinal menin 
gitis, 439 

Cerebro-spinal system, tuberculosis of, 405 

Cervicodynia, 1001 

Chenopodium, dose of the oil of, 832 

Cheyne-Stokes respiration in acute broncho- 
pneumonia, 698 

Chicken broth and jelly, preparation of, 244 

Chicken-pox, 605 

Chilblains, 365 

Chloral, dose of, 574 

Chloranaemia, 895 

Chlorate of potassium, dose of, at different 
ages, 624 

Chlorosis, 892 

Cholera asiatica, 505 
infantum, 502 

Chondrodystrophia foetalis, 342 

Chorea, 916; congenital, 977; electrica, 
924 ; habit, 924 ; hereditary or Hunting- 
ton's, 924; post-hemiplegic, 954 

Choreiform diseases, 924 

Chovstek's symptom, 943 

Chronic fermental diarrhoea, 809 
nervous diarrhoea, 798 

Chyluria, 850 

Cirrhosis of the liver, 838 

Citrate of potash, dose of, 574 

Cleft palate, 292 

Clothing of infants, 98-102 

Club-foot, 311 
-hand, 311 

Cocaine, doses of, 823 ; suppositories, 814 



INDEX. 



1011 



Colitis in measles, 593 

Colles's law in hereditary syphilis, 521 

Colon, dilatation of the, 810 ; irrigation of, 
the, 823 

Colostrum milk, 122 ; chemistry of, 122 ; 
corpuscles, 122 ; period, 122 ; influence of, 
on the infant's weight, 76 

Common carotid artery at term, 32 

Compensation of the heart. ( Vide the espe- 
cial diseases of the heart. ) 

Concussion, 937 

Condylomata in syphilis, 527 

Congenital chorea, 977 

disease, definition of, 19. ( Vide, also, 

Diseases of the new-horn. ) 
hydronephrosis, 865 ; stridor, 660 

Congestion, chronic passive, of the kidney, 
852 
of the liver, 835 

Conglomerate tubercles, definition of, 384 

Constipation, 798, 802 ; atonic, 803 ; spas- 
modic, 803 

Convulsions, 911 ; clonic, 911 ; epileptic, 
925 ; epileptiform, 925 ; general symptoms 
of, 912; of central origin, 912; of periph- 
eral origin, 913 ; prognosis in, 914 ; reflex, 
911, 913 ; tonic, 911 ; treatment of, 914 

Conus arteriosus, stenosis of the, 725 

Cor biloculare, 721 ; triloculare, 721 

Cord, encysted hydrocele of the, 306 ; in 
cerebro-spinal meningitis, 434 

Corrigan pulse in aortic insufficiency, 743 

Corrosive sublimate, strength of, in local 
applications, 869 

Coryza, acute, 640 

Cow, the, adaptability of, for infant feeding, 
169; Ayrshire, 168; Bretonne, 169 
Brown Swiss, 169 ; care of the, 170 
Devon, 168 ; Durham, or shorthorn, 168 
Holstein-Friesian, 169 ; source of milk- 
supply, 168 

Cow-pox. ( Vide Vaccinia. ) 

Cow's milk. ( Vide Milk of cows. ) 

Cows, tuberculin test of, 172 

Craniotabes in hereditary syphilis, 524, 529 ; 
in rhachitis, 333 

Cranium, 45 ; at term, 26. ( Vide, also, Face 
and cranium. ) 

Cream, definition of, 223 ; percentage com- 
position of different layers, 226, 227 

Creolin, strength of, in local applications, 869 

Cretinism, 901 ; endemic, 901 ; sporadic, 901 

Cricoid cartilage, 42 ; distance of the, to 
sternum, 43 

Croup, 662 ; false, 662 ; membranous, 662, 
664 

Culex, genus, in malaria, 482 

Curschmann's bronchiolitis exudativa, 673 ; 
spirals, 673 

Cyclic vomiting, 774 

Cystitis, acute, 865 ; chronic, 865 



Dactylitis syphilitica, 524, 529 
Degeneration, acute fatty, of the new-born, 

312 
Deglutition pneumonia, 691 
Dental periods, 50 
reflexes, 943 



Dentition, difficult, 634. ( Vide, also, Teeth. ) 

Depressed sternum, 297 

Dermatitis, 363 ; calorica, 365 ; exfoliativa 
neonatorum, 362 ; medicamentosa, 365 ; 
traumatica, 364 ; venenata, 364 

Descending colon in infants, 70 

Development, arrested psychical, 938 : nor- 
mal, 39 

Dextro-cardia, 721 

Diabetes insipidus, 1003 ; mellitus, 1004 ; 
pancreatic, 1005 

Diabetic coma, 1006 

Diacetic acid in diabetes mellitus, 1006 

Diameters of thorax at term, 30 

Diaphragm at term, 31 ; relations of, 53 

Diarrhoea, 793 ; acute fermental, 805 ; acute 
nervous, 796 ; chronic fermental, 809. 
( Vide, also, symptoms of the especial 
disease. ) 

Diet in the regimen of lactation, 136. ( Vide, 
also, Feeding, and the treatment of the 
especial disease. ) 

Difficult dentition, 634 

Digitalis, doses of, 470 

Dilatation, cardiac, 732 

Dilutions of cream, with solutions of sugar, 
231 ; with water, 231 ; with whey, 233 ; 
with whole milk, 231 

Diphtheria, 459; antitoxin in, 468, 470; 
atypical infections of throat in, 464 ; 
complications and sequela?, 466 ; diag- 
nosis, 466 ; efflorescence in, 467 ; etiology, 
460 ; incubation, 462 ; intubation in, 474 ; 
laryngeal, 465; malignant forms of, 464; 
nasal, 465 ; operative treatment, 474 ; 
pathology, 461 ; prognosis, 467 ; prophy- 
laxis, 468 ; serum-therapy in, 470 ; symp- 
toms, 462 ; tracheotomy in, 474; treatment, 
469 ; variations of type in, 464 

Diplegia, 953 

Diplococcus intracellularis meningitidis, 432 

Disseminated sclerosis, 987' 

Diuretin, dose of, 747 

Drugs in disturbed lactation, 138 

Ductless glands, diseases of the, 899 

Ductus arteriosus, persistence of the, 725 ; 
post-natal changes in the, 55 

Ductus venosus, post-natal changes in the, 55 

Duodenal indigestion, acute (vide Intestinal 
indigestion), 797; chronic, 798 

Duodenum at term, 34 

Dura mater, 47 

Dysentery (vide, also, Ileo-colitis), 820; 
chronic, 824 ; endemic, 501 ; tropical, 501 

Dvspepsia, acute, 778 ; chronic, 779 

Dystrophies, 990 

Dyspnoea. ( Vide symptoms of the especial 
disease. ) 

E. 

Ear, the, 47 ; at term, 29 ; diseases of, 644 ; 
in cerebro-spinal meningitis. 439 ; in diph- 
theria, 465 ; in measles, 582, 591 ; in pneu- 
monia, 682 ; in scarlet fever, 548, 570 ; in 
syphilis, 538 ; in variola, 599 ; reflex symp- 
toms of, 944 

Ear-drops, prescription for, 637 

Ears, protrusion of the, 293 

Eberth's bacillus, 447 



1012 



INDEX. 



Eclampsia infantum, 911 

Eczema, 369 ; regional, 369 ; universal, 370 

Emphysema, 706 ; compensatory, 706 ; in 
broncho-pneumonia, 696 ; interstitial, 706 ; 
obstructive, 706 

Empyema, 713 ; in measles, 593 ; in pneu- 
monia, 682 

Emulsion in modified milk, 203 

Encephalitis, acute, 984 

Encephalocele, 290 

Endocarditis, acute, 735 ; pathology, 736 ; 
septic or malignant, 735, 736, 738 ; 
simple or verrucous, 735, 736 ; treat- 
ment of, 739 ; ulcerative, 736 
chronic, 740 ; aortic insufficiency, 743 ; 
aortic stenosis, 744 ; diagnosis, 745 ; 
etiology, 740 ; general symptoms, 
740 ; mitral insufficiency, 741 ; mitral 
stenosis, 741 ; pathology, 740 ; prog- 
nosis, 745 ; pulmonary insufficiency 
and stenosis, 745 ; treatment, 746 ; 
tricuspid insufficiency, 744 ; tricuspid 
stenosis, 744 

Enemata, rectal, 830 

Enteric fever, 447 

Enuresis, 871 ; functional, 871 ; organic, 
871 

Eosinophiles, 875 ; percentage of, in the 
blood, 879 

Eosinophilic, 875 

Epidemic cerebro-spinal meningitis, 432 ; 
diagnosis, 440 ; etiology, 432 ; pathol- 
ogy, 433 ; prognosis, 440 ; symptoms, 
436 ; treatment, 440 ; types of the disease, 
435 

Epidemic pemphigus infantilis, 362 

Epididymitis, 870 

Epiglottis, 43 

Epilepsy, 925 ; grand mal, 925, 926 ; Jack- 
sonian, 925 ; petit mal, 925, 926 

Epileptic status, 927 

Epileptiform convulsions, 925 

Epiphyseal hyperemia, 970 

Epiphysitis, acute, 511 

Epispadias, 308 

Epistaxis, 644 

Epsom salt, doses of, 833 

Erb's juvenile form of progressive muscular 
atrophy, 993 

Erysipelas, 497 ; ambulans, 497 ; migrans, 
497 ; of the new-born, 498 ; of sucklings, 
498 

Erythema, 366 ; intertrigo, 367 ; multiforme, 
366 ; neonatorum, 324 ; nodosum, 367 ; 
simplex, 366 ; urticatum, 367 

Erythrocytes, 877, 880 

Eustachian tubes, 48 ; at term, 28 

Eustachian valve, post-natal change of the, 
55 

Examination and treatment, general princi- 
ples of, auscultation, 250 ; history, 247 ; 
inspection, 248 ; lumbar puncture, 253 ; 
method of examining a child, 246 ; palpa- 
tion, 248 ; percussion, 249 ; prophylaxis, 
256 ; respiration, 248 ; Rontgen light, 
253 ; temperature, 248 ; treatment in gen- 
eral, 255 

Exanthemata, the, as a group, 542 ; differ- 
ential diagnosis of, 612 

Exercise in the regimen of lactation, 137 



Exophthalmic goitre, 905 

Extremities, diseases of the, in the new- 
born, 310; inrhachitis, 336; length of, in 
cretins, 902 

Eye, at term, 29 ; in cerebro-spinal menin- 
gitis, 438 ; in measles, 592 ; in syphilis, 
526, 538 

F. 

Eace and cranium, at term, 26 ; develop- 
ment of, 45 

Faecal dejections, influence of fat on the 
color of the, 216 

Faeces, incontinence of, 802 

False asthma, 674 
croup, 662 

Fat-free milk, composition of, 227 ; defini- 
tion of, 223 

Fats in human milk, 124, 127, 128 

Fatty degeneration, acute, in the new-born, 
312 
of the heart, 734 

Fatty infiltration of the heart, 734 ; of the 
liver, 836 

Faucial tonsils at term, 28 

Feeding, 160 ; after the twelfth month, 243 ; 
amounts of food in, 67, 68 ; amount at 
each, 188 ; apparatus, 186 ; by stomach- 
tube, 781 ; direct substitute, 160 ; directly 
from animals, 164 ; general principles of, 
112; general rules for, during first year, 
188 ; indirect substitute, 164 ; intervals of, 
135, 188 ; intervals and number of, 136 ; 
maternal, vide Maternal feeding ; mixed, 
156 ; nipples in, 188 ; of average infants 
born at term, 214 ; of premature infants, 
273 ; Ssnitkin's rule, 189. ( Vide, also, 
Percentage feeding. ) 

Feeding-card, 229 

Feet, 81 ; at term, 37 ; care of, in children, 
102 

Femoral hernia in the new-born, 305 

Fibroid phthisis, 695 

Filaria sanguinis hominis, 850 

Fingers in the new-born, 310 

Fissures, 813 

Fistulse, 814 

Flat-foot, 81 

Flexner's bacillus, 820 

Foetal circulation, 19 
rhachitis, 342 

Fontanelles at term, 25 ; development of, 45 

Food, artificial, for infants, 240 ; malted, 
241 ; management of, in early days of life, 
135 ; source of, in indirect substitute feed- 
ing, 166 

Foramen ovale, open, 723 ; post-natal 
changes in the, 55 ; premature closure of 
the, 723 

Forced feeding, 781 

Forchheimer's exanthem in rubella, 594 

Foreign bodies in the larynx, 661 ; in the 
oesophagus, 768 

Formulae, general, for calculation of all 
percentage combinations, 235 ; for calcula- 
tion of sugar percentage, 231 ; for cream 
and fat-free milk, 237 ; for cream and 
whey, 238 ; for cream and whole milk, 
236 

Fossa of Rosenmuller, 28 



INDEX. 



1013 



Fraenkel's pneumococcus, 675 

Freckles, 376 

Friedlander, bacillus of, 691 

Friedreich's disease, 988 

Frowlowsky's rule for gastric capacity, 59 

Functions, development of, 82 

Funnel chest in rhachitis, 334 

Furunculosis, 358 

G. 

Gangrene of the lung, 707 ; in pneumonia, 
682 

Gastralgia, 777 

Gastric catarrh, acute, 789 ; chronic, 792 

Gastritis, acute, 789 ; catarrhalis acuta, 789 ; 
chronic catarrhal, 792; corrosiva acuta, 
789, 791 ; pseudo-membranosa, 789, 791 

Gastro-diaphane, 785 

Gastro-enteric diseases, American Pediatric 
Society's classification of the, 769, 773 ; 
general bacteriology, 770 ; general diag- 
nosis, 771 ; general etiology, 770 ; general 
symptomatology, 771 ; general treatment, 
772 ; table of classification, 773 

Gastro-enteric tract, tuberculosis of the, 399 

Gavage, 780 

Genitals, diseases of the, 865 

German measles. ( Vide Kubella. ) 

Giant urticaria, 379 

Glioma, 978 

Glossitis, 633 

Glottis, oedema of, in measles, 593. ( Vide, 
also, the especial disease. ) 

Glycosuria, 851 ; alimentary, 851 ; dietetic, 
851 ; in scarlet fever, 573 ; temporary ali- 
mentary, 1005 

Goitre, 899 ; exophthalmic, 905 

Grand mal, 925, 926 

Green sickness, 893 

Growing pains, 970 

Gum-lancing, 636 

Gums at term, 27 

Gyrospasm, 944 

H. 

Habit chorea, 924 

Hsematoblasts, 874 

Hematoma of the sterno-cleido-mastoid, 295 

Hematuria, 849 ; in chlorosis, 893 ; in per- 
nicious anaemia, 890 ; in scorbutus, 344 ; 
in secondary anaemia, 895 

Hsemoglobin, 875, 876, 880 

Haemoglobinaemia, 875 

Hemoglobinuria, 849, 875 ; paroxysmal, 849 
infectious, in the new-born, 314 

Haemolysis, 875 

Haemopericardium, 754 

Haemophilia, 997 

Hands at term, 37 

Hard palate, 29, 48 

Harelip, 291 

Harrison's groove in rhachitis, 334 

Headaches, 939 

Head, anencephalic, 290 ; at term, 25 ; de- 
velopment of the, 43 ; diseases of the, in 
the new-born, 286 ; in rhachitis, 333 ; 
macrocephalic, vide Hydrocephalus ; mi- 
crocephalic, 932 

Hearing at term, 38 



Heart, at term, 32; diseases of the, 719; in 
scarlet fever, 554 ; post-natal changes 
in the, 54 ; reflex symptoms of the, 
948 
acquired diseases of the, 730 ; amyloid 
degeneration, 734 ; brown atrophy, 
734 ; calcareous degeneration, 734 ; 
dilatation, 732 ; endocarditis, 735 ; 
fatty degeneration, 734 ; fatty infiltra- 
tion, 735 ; hyaline transformation, 
734 ; hvpertrophy 731 ; myocarditis, 
733 
congenital diseases of the, 720 ; defect 
of the ventricular septum, 724 ; dif- 
ferential diagnosis of the, 726 ; gen- 
eral diagnosis, 723 ; general symp- 
toms, 721 ; general treatment, 730 ; 
lesions of the aortic valve in, 726; 
lesions of the mitral valve in, 726 ; 
open foramen ovale in, 723 ; per- 
sistence of the ductus arteriosus in, 
725 ; pulmonary atresia in, 725 ; pul- 
monary stenosis in, 724 ; transposi- 
tion of the large arteries in, 726 ; tri- 
cuspid insufficiency in, 726 ; tricuspid 
stenosis in, 726 ; stenosis of the conus 
arteriosus in, 725 
functional diseases of the, 748 
murmurs. ( Vide lesions of the especial 
valves. ) 
Heat-stroke, 935 
Height, at term, 36, 73 ; in infancy and 

childhood, 73 
Hemiplegia, 953 
Hemitaxia, 954 

Hemorrhage in early life, 317 ; in scorbutus, 
344 ; in syphilis, 526 ; in typhoid fever, 
448, 450. ( Vide, also, symptoms of the 
especial disease. ) 
Hemorrhagic diathesis, 997 
Hemorrhagic disease of the new-born, 317 
Hemorrhoids, 814 
Henoch's purpura, 999 
Hepatitis, interstitial, 838 ; atrophic and 

hypertrophic, 838 ; suppurative, 836 
Hepatization, red and gray, 676 
Hereditary ataxia, 988 
chorea, 924 
spastic paralysis, 989 
syphilis. ( Vide Syphilis. ) 
Hernia, 813 ; congenital, funicular, and in- 
fantile, 304 ; inguinal, 304 
Herpes zoster, 374 
Hip, congenital dislocation of the, 311 ; 

tuberculosis of the, 429 
Hives, 367 

Holt's cream-gauge, 124 
Home modification of milk, 217 ; apparatus 
for, 224 ; definition of terms in, 223 ; diffi- 
culties and dangers of, 217 ; final remarks 
on, 239 ; materials for, 223 ; method of 
obtaining cream and separated milk for, 
225 ; table for calculation of, 228. ( Vide, 
also, Formulae. ) 
Human milk. ( Vide Milk, human. ) 
Huntington's chorea, 924 
Hyaline transformation of the heart, 734 
Hydatids of the liver, 837 
Hydrocele, 305 ; congenital, infantile, and 
funicular, 305 ; in the new-born, 305 



1014 



INDEX. 



Hydrocele, encysted, of the canal of Nuck, 

306 ; of the cord, 306 
Hydrocephalic cry, 408 
Hydrocephalus, 970 ; acute, 970 ; chronic 

internal, 971 ; congenital, 291 ; external, 

970 ; internal, 970 ; in vacuo, 971 
Hydronephrosis, 865 
Hydropericardium, 754 
Hydrothorax, 717 

Hyperemia, epiphyseal, 970 ; passive, 852 
Hyperpyrexia, treatment of, "by bathing, 455 
Hyperthyrea, 905 
Hypertrophic pulmonary osteo-arthropathy, 

1008 
Hypertrophy, cardiac, 731 
Hypnotic state, 935 
Hypospadias, 308 
Hypostatic pneumonia, 705 
Hysteria, 932 

I. 

Ichthyosis, 377 ; fcetal, 377 ; neonatorum, 378 

Icterus, 835 ; neonatorum, 323 

Idiocy, 930 

Ileo-colitis, 820; acute (simple catarrhal), 
821; amoebic, 501, 820; chronic, 824; 
diagnosis, 822 ; general etiology, 820 ; non- 
ulcerative follicular, 821 ; pathology, 821 ; 
prognosis, 823 ; pseudo-membranous, 821, 
822 ; treatment, 823 ; tubercular, 399 ; 
typhoidal, 447 ; ulcerative, 821 822 ; 
variations in the type of, 820 

Imbecility, 930 

Impetigo contagiosa, 357 

Incubator for premature infants, 266 

Indigestion, acute gastric, 778 ; acute intes- 
tinal (duodenal), 797 ; chronic duodenal, 
799 ; chronic gastric, 779 ; chronic intes- 
tinal, 802 ; chronic nervous intestinal, 798 ; 
chronic tubular, 798 

Infant at term, the, 21 ; abdomen, 33 ; bile, 
38 ; bladder, 36 ; blood, 38 ; bone-marrow, 

37 ; brain, 29 ; bursa pharyngea, 28 ; com- 
mon carotid artery, 32 ; cranium and face, 
26 ; diameters of thorax, 30 ; diaphragm, 
31 ; duodenum, 34 ; ear, 29 ; Eustachian 
tubes, 29 ; eye, 29 ; faucial tonsils, 28 ; 
feet, 37 ; fcetal circulation, 19 ; fontanelles, 
25 ; general description of, 21 ; head, 25 ; 
hands, 37 ; hard palate, 29 ; hearing in, 

38 ; heart, 32 ; height, 36, 73 ; intestines, 
35 ; intestinal discharges, 39 ; jaws, 26 ; 
kidneys, 33 ; lachrymal glands, 38 ; large 
intestines, 36 ; larynx, 25 ; liver, 33 ; 
lungs, 32 ; lymph-vessels of pharynx, 27 ; 
lymphatic system, 39 ; lymphoid tissues, 

28 ; mastoid antrum, 29 ; meconium, 39 ; 
mouth, 29 ; naso-pharynx, 27 ; neck, 24 ; 
ossification of sternum, 30 ; pancreas, 39 ; 
pelvis, 36 ; petro-squamosal suture, 30 ; 
pharyngeal tonsil, 28 ; pulse, 36 ; respira- 
tion, 33, 36, 72 ; salivary glands, 38 ; se- 
baceous glands, 38; sight, 37; skin, 21; 
small intestines, 36 ; smell, 38 ; soft palate, 

29 ; spine, 22 ; sternum, 30 ; stomach, 34 ; 
suprarenal capsule, 33 ; sweat-glands, 38 ; 
taste, 38; teeth, 29; temperature, 36, 70; 
thorax, 30 ; thymus gland, 32 ; tongue, 
29; touch, 38; uric acid infarction, 34; 
urine, 39, 85 ; uterus, 36 ; uvula, 29 ; 



veins, 32 ; vernix caseosa, 21 ; vitality, 
37 ; voice, 37 ; weight, 36 
Infantile atrophy, 348 
cerebral palsies, 950 
spinal paralysis, 958 
Infantilism, 537 

Infants, normally developed, 88 ; prema- 
ture, vide Premature infants ; when to 
take out of the house, 106 
Infectious diseases, specific, 381 

haemoglobinsemia of the new-born, 314 
hemoglobinuria, 314 
Influenza, epidemic, 476 ; febrile type, 478 
gastro-enteric type, 478 ; nervous type, 
478 ; pseudo-, 476 
Inguinal hernia in the new-born, 304 
Insanity, 929 
Insolation, 935 
Insular sclerosis, 987 
Intention tremors, 987 

Intestinal contents, 793 ; amount, 795 ; 
color, 793 ; composition, 794 ; con- 
sistency, 794 
discharges at term, 39 ; in infancy, 87 
Intestines, at term, 35 ; congenital oblitera- 
tion of, 310 ; development of, 68 
developmental diseases of the, 795 ; 
malformations, 795 ; malpositions, 795 
diseases of the, 767, 793; American 
Pediatric Society's classification of 
the, 769, 773 ; diarrhoea in, 793 ; gen- 
eral considerations of, 793 ; intestinal 
contents in, 793 ; prophylaxis in, 793 
functional diseases of the, 795 ; acute 
indigestion, 797 ; acute nervous, 796 
chronic duodenal indigestion, 799 
chronic intestinal indigestion, 802 
chronic nervous, 798 ; chronic tubu- 
lar, 798 ; constipation, 802 ; elimina- 
tive, 805 ; incontinence of feces, 802 
organic diseases of the, 805 ; acute fer- 
mental, 805; appendicitis, 815; 
chronic fermental, 809 ; dilatation of 
the colon, 810 ; dysentery, 820 (vide, 
also, Ileo-colitis) ; fissures, 813 ; fis- 
tulas, 814 ; hemorrhoids, 814 ; hernia, 
813 ; intussusception, 811 ; mechani- 
cal, 809 ; new growths, 814 ; polypi, 
814 ; proctitis, 815 ; prolapse, 813 ; 
volvulus, 811 
Intussusception, 811 

Iodide of potash, dose of, in syphilis, 538 
Iron, dose of, in chlorosis, 893 
Irrigation of colon, 823 ; nasal, 473 
Irritation of kidney, acute, 851 
Isthmus aortse, absence of, 720 ; narrowing 

of, 720 
Ivy poisoning, 364 

J. 

Jacksonian epilepsy, 925 
Jalap, compound powder of, dose of, 574 
Jaws at term, 26 

Joints in cerebro-spinal meningitis, 439 ; in 
scarlet fever, 575 ; tuberculosis of the, 427 

K. 

Kakke, 985 

Kaposi's disease, 376 

Keratitis, interstitial, in syphilis, 538 

Kernig's sign, 409 



INDEX. 



1015 



Kidneys, at term, 33 ; in cerebrospinal 
meningitis, 435 ; in childhood, 57 ; 
enlargement of the, 866 ; in measles, 
592 ; "in scarlet fever, 553, 572 ; dis- 
eases of the, 844 
acquired diseases of the (vide, also, 
Nephritis) ; acute irritation, 851 
acute pyelitis and pyelonephritis, 862 
albuminuria of adolescence, 848 
amyloid infiltration, 859 ; anuria 
847 ; chronic passive congestion, 852 
general etiology of, 844 ; general pa- 
thology of, 844 ; general symptoma- 
tology of, 846 ; hematuria, 849 ; 
hsemoglobinuria, 849 ; malignant 
growths, 866 ; passive hyperaemia, 
852 ; physiological albuminuria, 847 : 
tuberculosis, 431 
congenital diseases of the, 844 

Klebs-Loeffler bacillus, 459 

Knee, congenital dislocation of the, 311 ; 
tuberculosis of the, 429 

Knock-knee, 111 

Koplik's gastro-diaphane, 785 

spots in measles, 583 ; in rubella, 594 

Kumyss, 241 

Kyphosis in rhachitis, 336 

L. 

Laboratory modification of milk, practical 
limits of, 199 

Lachrymal glands at term, 38 ; development 
of, 82 

Lactalbumin, 178; definition of, 223 

Lactation, disturbed, 138 ; analyses of hu- 
man milk in, 143 ; general principles 
for the management of, 140, 141 ; 
menstruation in, 139 
prolonged, 156 
regimen of, 136 

Lacto-globulin, 178 

Lagophthalmia, 969 

La grippe, 476 

Landouzy-Dejerine type of progressive mus- 
cular dystrophy, 993 

Landry's paralysis, 986 

Large intestines at term, 36 ; development 
of, 69 

Laryngismus stridulus, 660 

Laryngitis, 662 ; acute catarrhal, 662 ; 
chronic, 662 ; membranous, 465, 593, 664 

Laryngospasmus, 660, 944 

Larynx, 43 ; at term, 25 ; diseases of the, 660 ; 
foreign bodies in the, 661 ; new growths, 
660 ; oedema of, 662 ; pseudo-membranous, 
664 ; reflex symptoms of the, 944 

Lavage, 780 

Leg type of progressive muscular atrophy, 991 

Lentigo, 376 

Leptomeningitis, 981 

Letter S curve, 710 

Leucocytes, 874, 881 ; in children, 877 

Leucocytosis, 875 ; in children, 881 ; in 
secondary anaemia, 895. ( Vide, also, symp- 
toms and diagnosis of the especial disease. ) 

Leukaemia, 882 ; lymphatic, 883 ; splenic 
myelogenous, 882 

Lichen planus, 377 

Lingua geographica, 633 



Lipoma of the brain, 978 

Liver, abscess of the, 836 ; acute yellow 
atrophy of the, 835; anatomy, 834; at 
term, 33 ; amyloid, 837 ; in cerebro-spinal 
meningitis, 435 ; in childhood, 57 ; cir- 
rhosis, 838 ; congestion, 835 ; diseases of 
the, 834 ; fatty infiltration, 836 ; hydatids, 
837 ; icterus, 835 ; new growths, 837 ; in 
syphilis, 522 ; tuberculosis of, 431 

Lobular pneumonia, 691. ( Vide, also, 
Broncho-pneumonia. ) 

Locomotor ataxia, 989 

Lordosis in rhachitis, 336 

Lumbago, 1001 

Lumbar puncture, 253 

Lungs, the, abscess of, 707 ; acute miliary 
tuberculosis of, 393 ; at term, 32 ; chronic 
localized tuberculosis of, 395 ; chronic dif- 
fuse tuberculosis of, 395 ; development of, 
56 ; diseases of, 665 ; gangrene of, 707 ; 
in cerebro-spinal meningitis, 434, 438 ; re- 
flex symptoms of, 946 ; syphilis of, 523 ; 
tuberculosis of, 393 

Lupus, 432 

Lymphangioma cavernosum, 634 

Lymphatic leukaemia, 883 

system at term, 39 ; development of, in 
early life, 83 

Lymphatism, 1000 

Lymph-nodes, diseases of the, 897 ; in cere- 
bro-spinal meningitis, 435 
cervical, in measles, 592 ; in scarlet 
fever, 549, 569; in syphilis, 525; 
in tuberculosis, vide Tuberculosis of 
the lymph-nodes 

Lymphocytes, 878 ; large, small, mono- 
nuclear, and transitional, 874 

Lymphoid tissue at term, 28 

Lymph vessels of the pharynx at term, 27 

M. 

Macrocytes, 874 

Microglossia, 634 

Malaria, 481 ; chronic, 488 ; diagnosis, 488 
etiology, 481 ; genus anopheles in, 481 
genus culex in, 481 ; intermittent, 485 
pathology, 485 ; paroxysms in, 486 ; prog- 
nosis in, 488 ; prophylaxis in, 489 ; remit- 
tent, 485 ; symptoms, 485 ; subacute forms, 
488 ; treatment, 489 

Male fern, oleoresin of, dose of, 832 

Malformations of intestines, 795 

Malignant endocarditis, 736, 738 ; septic 
type, 739 ; typhoidal type, 739 

Malignant growths. ( Vide New growths 
and tumors.J 

Malposition of the intestines, 795 

Malted foods, 241 

Mammary gland, 114 

Marasmus, 348 

Marmorek's antistreptococcus serum in scar- 
let fever, 562 

Mastitis, 118 ; in the new-born, 296 

Mastoid antrum at term, 29 

Masturbation, 873 

Maternal feeding, 116 ; contraindication to, 
117 

Maternal impressions, 285 

Matzoon, 241 

Maxillarv bones, 48 



1016 



INDEX. 



Measles, 579 ; complications and sequelae of, 
590 ; contagium in, 580 ; desquamation 
584, 589 ; diagnosis, 584 ; efflorescence 
584, 588 ; etiology, 579 ; incubation, 582 
588 ; hemorrhagic or malignant form, 588 
pathology, 581 ; prodromata, 582, 588 
prognosis, 585 ; recurrent, 589 ; relapses 
589 ; symptoms, 582 ; treatment, 585 
variations in type, 587 
Meckel's diverticulum, 303 
Meconium, 39 
Megaloblasts, 874 
Megalocytes, 874 
Melsena neonatorum, 320 
Melanoderma lenticularis progressiva, 376 
Meningitis, 981 ; basilar, 982 ; cerebral, 
table of diagnosis, 415; epidemic cerebro- 
spinal, 432 ; in pneumonia, 684 ; serosa, 
971 ; simple acute, 982 ; tubercular, 406 : 
tubercular, infantile form, 410 
Meningocele, 289 
Meningo-myelitis, 958 

-myelocele, 298 
Menstruation in disturbed lactation, 139 
Mental development in syphilis, 537 
Mental impressions, development of, 82 
Mercurials, use of, in syphilis, 531 
Microbials, 874 
Microcephalus, 932 
Micrococcus lanceolatus, 676 
Microcytes, 874 
Microglossia, 634 
Microsporon furfur, 360 
Migraine, 940 

Miliary tubercles, definition of, 384 
Miliary tuberculosis, 387. ( Vide Tubercu- 
losis. ) 
Milk, 120; care of, 172; formation of, 120; 
home modification of, 217 (vide, also, 
Home modification) ; nervous disturb- 
ances affecting the, 121 ; peptoniza- 
tion of, 202 
human, 124 ; analyses in disturbed lac- 
tation, 143 ; average analyses of, 127 
(vide, also, the analyses in the illus- 
trative cases of breast and substi- 
tute feedings, 143-155 and 210-213) ; 
bacteriological examination of, 134 ; 
clinical examination of, 124 ; clinical 
significance of the chemistry of, 127 ; 
fats, 124, 128 ; lactose or milk-sugar, 
126, 129 ; microscopic examination, 
126 ; mineral matter, 126, 129 ; pro- 
teids, 125, 129, 200; specific gravity, 
124, 128; water, 128; variations, 132 
-laboratories, 184, 189 ; apparatus for 
transportation of modified milk, 193 ; 
Babcock fat-tester, 191 ; milk-room, 
190 ; modifying-room, 191 ; separa- 
ting-room, 191 ; separator, 191 ; ster- 
ilization of the milk, 196 ; still, 191 ; 
ventilator, 191 ; wash-room, 197 
of cows, as compared with woman's 
milk, 180; attenuants, 179; average 
analysis, 173; bacteriology, 180; fats, 
175 ; lactose or milk-sugar, 176 ; milk 
plasma, 176 ; mineral matter, 178 ; 
proteids, 177, 200; reaction, 174; 
specific gravity, 175 
of magnesia, dose of, 805 



Mirror writing, 932 
Mitral insufficiency, 741 

orifice, lesions of, in congenital disease, 

726 
stenosis, 741 
Modification of milk, materials for, 195; 
practical limits of, in the milk-laboratories, 
199. ( Vide,- also, Formulae, Home modi- 
fication, and Feeding. ) 
Modified milk, the emulsion in, 203 
Molluscum contagiosum, 358 
Monoplegia, 953 

Morbus maculosus Werlhofii, 999 
Morphine, doses of, 505, 824 
Mouth at term, 29 ; care of the, 107 ; in 
syphilis, 527 
diseases of the, 615 ; nomenclature, 

615 ; table of classification of, 616 
-wash, 653 
Mucous polypi of the nose, 643 
Multiple neuritis, 985 
Mumps, 613 ; submaxillary, 614 
Murmurs, heart, congenital, 727 ; func- 
tional, 749 ; organic, 749. ( Vide, also, 
the especial valvular lesion. ) 
Muscular atrophy, progressive central, 989 ; 
progressive neural, 990, 991 
dystrophies, atrophic form, 995 ; classi- 
fication of the, 993 ; Erb's juvenile 
form, 993, 995; Landouzy-jDejerine 
type, 993, 995 ; pseudo-hypertrophic 
form, 994 
rheumatism, 1001 

tremors in exophthalmic goitre, 906 
Mutton broth, preparation of, 245 
Myalgia, 1001 
Mycelium, 626, 628, 629 
Myelitis, acute, 958 
Myelocytes, 875, 878; eosinophilic, 875; 

neutrophilic, 875 
Myocarditis, interstitial, 733 ; parenchyma- 
tous, 733 
Myoclonia, 925 
Myomalacia, 734 
Myopathies, 990 ; primary, 993 
Myotonia congenita, 924 
Myotonic reaction, 924 
Myxoedema, 901 ; acquired, 901 ; congenital, 

901 ; operative, 901 
Myxoma of the brain, 978 

N. 

Naevus, 325 

Nails in syphilis, 526, 538 

Napkins, 39, 84, 87, 793 

Nasal irrigation, 473 

Naso-pharvnx, 47 ; at term, 27 ; diseases of 

the, 645" 
Natiform skull in late hereditary syphilis, 537 
Neck, at term, 24 ; development of the, 42 

diseases of the, in the new-born, 295 
Nephritis, acute, 853 ; acute diffuse, 853 ; 

catarrhal, 852 ; chronic interstitial, 

857 ; chronic parenchymatous, 855 ; 

subacute glomerular, 855. ( Vide, also, 

Kidney. ) 
pathology of acute degenerative, acute 

glomerular, acute hemorrhagic, acute 

interstitial, 549-553, 853 



INDEX. 



1017 



Nerves and nerve ganglia in cerebro-spinal 

meningitis, 434 
Nervous disturbances affecting the milk, 121 
system, diseases of the, 910 

in cerebro-spinal meningitis, 433 
Nettle-rash, 367 
Neuralgia, 970 
Neuritis, multiple, 985 
Neutrophiles, 875 
Neutrophilic, 875 

New-born, the, acute fatty degeneration of, 
312 ; asphyxia in, 312 
diseases of, 282 ; erysipelas of, 498 ; 
extremities in, 310 ; general diag- 
nosis, 285 ; general diseases, 312 ; 
general etiology, 283 ; general 
pathology, 283 ; general prog- 
nosis, 285 ; general symptoms, 
284 ; head in, 286 ; hemorrhage 
in the, 317 ; hemorrhagic disease 
of, 317 ; infectious hasmoglobi- 
nsemia of, 314 ; infectious hemo- 
globinuria of, 314; inheritance 
in, 282 ; malformation in, 282 ; 
maternal impressions as a factor 
in, 285 ; neck in, 295 ; paralysis 
of, 968 ; syphilis of, 521 ; trau- 
matism in, 282 ; trunk in, 296 
New growths of the intestines, 814 ; . of 
the larynx, 660 ; of the liver, 837 ; of the 
stomach, 783, 789. ( Vide, also, Tumors. ) 
Nipples, 118, 188 

Nitrate of silver, strength of, in local appli- 
cations, 869 
Nitroglycerin, doses of, in children, 470 
Noma, 629 ; in measles, 593 
Normal development, 39 
infant, the, at term, 18 
maternal conditions, 116 
salt solution, dose for subcutaneous in- 
jection of, 504 
Normoblasts, 874 
Nose, diseases of the, 640 
Nursery, the, 93 ; bed, 94 ; closets and 
drawers, 94 ; curtains, 94 ; draughts, 95 ; 
floor, 93 ; furniture, 94 ; heating and ven- 
tilation, 95 ; papers and carpet in, 93 ; 
picture mouldings, 93 ; pillow and mat- 
tress, 94 ; rugs, 93 ; scales, 95 ; sun and 
windows, 93 ; toys, 94 ; walls and ceil- 
ings, 93 
Nursery-maids, 107 
Nursing, 117 ; irregularity in, 136 
Nutrition, diseases of, 326 ; relation of 

weight to, 73-81 
Nutritive period, first, 116 ; second, 241 ; 

third, 245 
Nux vomica, dose of, 805 
Nystagmus, 944, 988 



Oat-gruel, 239 

-jelly, preparation of, 239 
-water, 239 
Obstetrical paralysis, 968 
O'Dwyer's tubes in intubation, 476 
(Edema of the larynx, 662 ; neonatorum, 
323. ( Vide, also, symptoms of the 
especial disease. ) 
(Esophagitis, 767 



(Esophagus, congenital dilatation of the, 
769 ; diseases of the, 767 ; foreign bodies 
in the, 768 

Oi'dium albicans, 626 

Oligocvthemia, 875 

Omodynia, 1001 

Onychia, 526, 538 

Ophthalmia neonatorum, 294 ; catarrhal, 
294 ; purulent, 294 

Opium, doses of the tincture of, 823 

Orchitis, 870 

Ossification of the sternum, 30 ; of the 
thorax, 51 

Osteo-arthropathy, hypertrophic pulmo- 
nary, 1008 

Osteomalacia, 343 

Osteomyelitis, acute infectious, 511 

Osteoperichondritis in hereditary syphilis, 
524, 528 

Osteoperiostitis in hereditary syphilis, 523 

Otitis media. ( Vide Ear. ) 

Oxyphiles, 875 

Oxyuris vermicularis, 829 

Ozaena, 643 

P. 

Pachymeningitis, 981 

Palsies, birth, 951 ; extra-uterine, 951 ; in- 
fantile cerebral, 950 

Paludism. ( Vide Malaria. ) 

Pancreas, the, at term, 38 ; in childhood 
57 ; development of the function of, 83 
diseases of the, 840 ; tuberculosis of, 430 
in syphilis, 523 

Pancreatic diabetes, 1005 

Paralysis, bulbar, 985 ; caused by caries of 
the spine, 967 ; cerebral, 950 ; hereditary 
spastic, 989 ; in cerebro-spinal meningitis, 
437 ; infantile spinal, 958 ; in measles, 
593 ; in tuberculosis of the spine, 429 ; 
Landry's, 986 ; obstetrical, 968 

Paramyoclonus multiplex, 925 

Paramyotonia, congenital, 925 

Paraplegia, 953 

Parasites. ( Vide Animal parasites.) 

Parotitis, 613 

Paroxysmal gasping, 946 

Parrot's disease, 528 

Pavor nocturnus, 941 

Pectus carinatum, 334 

Pediculosis, 357 

Pediculus capitis, 357 

Peliosis rheumatica, 998 

Pelletierine, dose of, 832 

Pelvis at term, 36 

Pemphigus, 361 ; neonatorum, 361 ; puru- 
lent, 362 ; syphilitic, 525 

Peptonized milk, 241 

Percentage combinations, for premature in- 
fants, 274 ; calculation of, 226 
feeding, illustrative cases in, 206 ; prin- 
ciples of prescription-writing in, 197 ; 
use of whey in, 200, 201 ; whey-cream- 
mixtures in, 201, 229 

Perforation in typhoid fever, 448, 450 

Pericarditis, acute, 754 ; diagnosis, 759 ; dry, 
755; etiology, 754; in measles, 593 ; plas- 
tic, 755 ; paracentesis in, 762 ; pathology, 
754 ; physical signs, 755 ; in pneumonia, 
682; treatment, 762; with exudation, 755 



1018 



INDEX. 



Pericarditis, chronic adhesive, 764 
Pericardium, diseases of the, 719, 754 
Perinephritis, 862 

Peritoneum, diseases of the, 840 ; tubercu- 
losis of the, 401 
Peritonitis, acute, 840 ; acute pneumococcus, 
842 ; chronic, 843 ; congenital, 843 ; gen- 
eral suppurative, 817 ; of the new-born, 
842 ; peri-appendicular, 817 ; with septi- 
caemia, 818 
Peritonsillar abscess, 654 
Perles of Laennec, 673 
Pernicious anaemia, 890 

Peroneal type of progressive muscular atro- 
phy, 991 
Pertussis, 505 ; complications, 508 ; diagno- 
sis, 509 ; etiology, 505 ; incubation, 506 ; 
in measles, 590 ; pathology, 506 ; progno- 
sis, 509 ; prophylaxis, 510 ; symptoms, 
506 ; treatment, 510 
Petit mal, 925, 926 

Petro-squamosal suture, 47 ; at term, 30 
Peyer's patches in typhoid fever, 448 
Pharyngeal tonsil, 48 ; at term, 28 ; hyper- 
trophy of, 645 
Pharyngitis, 654 ; acute follicular, 655 ; 
acute simple, 654 ; chronic, 655 ; elonga- 
tion of uvula in, 655 
Pharynx, diseases of the, 649 
Phenacetine, dose of, in infants, 701 
Phimosis, 870 . 
Phlebitis umbilicalis, 301 
Phosphate of soda, dose of, 805 
Phthisis, fibroid, 695 
Pigeon-breast, 334 
Pilocarpine, dose of, 574 
Pityriasis, 375 

maculata et circinata, 375 ; rosea, 375 ; 
rubra, 375 
Plaques muqueuses, 528 

Plasmodium malaria?, 483 ; sestivo-autumnal 
parasite, 484 ; tertian parasite, 484 ; quar- 
tan parasite, 484 
Pleura, diseases of the, 707 ; tuberculosis of 

the, 399 
Pleurisy, acute, 707 ; acute dry or plastic, 
708 ; etiology, 707 ; primary forms of, 
707 ; secondary forms of, 707 ; with 
purulent exudation, 713 ; with sero- 
fibrinous exudation, 708 
chronic, 716 
Pleuritis in measles, 591 
Pleurodynia, 1001 
Pleuro-pneumonia, 708 

Pneumococcus lobar pneumonia, 675, 676. 
( Vide Pneumonia, pneumococcus 
lobar. ) 
of Praenkel, 675, 676 
Pneumonia. 675 ; abortive, 681 ; acute 
croupous, 675 ; acute fibrinous, 675 ; 
apex, 681; aspiration, . 691 ; central, 
681 ; cerebral, 681 ; definition of, 675 ; 
deglutition, 691 ; hypostatic, 705 ; 
massive, 681 ; migratory or creeping, 
681 
lobar, due to other organisms than the 

pneumococcus, 690 
pneumococcus lobar, 675, 676 ; compli- 
cations and sequela?, 682 ; crisis in, 
679 ; delayed resolution, 681 ; diag- 



nosis, 683 ; etiology, 676 ; pathology, 
676 ; physical signs, 680 ; prognosis, 
685 ; symptoms, 677 ; treatment, 685 ; 
varieties, 681 

Pneumopericardium, 754 

Pneumothorax, 717 

Podophyllin, dose of, 574, 801 

Poikilocytes, 874 

Poikilocytosis, 895 

Polioencephalitis, 985 

Poliomyelitis, anterior acuta, 958 

Polychromatophilic, 875 

Polynuclear leucocytes, 875 
neutrophiles, 878 

Polypi of the nose, 643 ; of the rectum, 814 

Posthitis, 870 

Posture, defects of, 108 

Percentage feeding, 184 

modification, theory of, 231 

Porencephalus, 951 

Pregnancy in disturbed lactation, 139 

Premature infants, 257 ; abdomen, 259 ; air, 
262 ; animal heat, 262 ; appearance at 
birth, 264 ; amyolytic function in, 261 
Breck's feeder for, 272 ; circulation, 262 
determination of the age of, 257 ; digestion 
in, 261 ; feet, 260 ; gastric capacity, 260 
head, 259 ; incubator for, 266 ; intestinal 
contents, 262; kidney, 262; light, 263 
normal development of, 259 ; prognosis 
275 ; pulse, 263 ; respirations, 263 ; skin 
259 ; sound, 263 ; sweat-glands, 259 ; tern 
perature, 263 ; thorax, 259 ; touch, 263 
treatment, 264; weight, 265 

Prescriptions for home modification, 228 
for whey-cream mixtures, 201, 229 

Prescription-writing in percentage feeding, 
197, 226-230 

Primary anaemia, 890 

Proctitis, 815 

Progressive interstitial hypertrophic neuritis 
of infants; 993 

Prolapse of rectum, 813 

Prominent sternum in the new-born, 298 

Protargol, strength of, in local applications, 
869 

Proteids in cow's milk, 200 ; in human milk, 
125, 127, 129, 200; determination of, in 
human milk, 125 

Prurigo, 373 ; ferox, 374 ; mitis infantilis, 
373 

Pseudo-bulbar paralysis, 985 

Pseudo-leukaemic anaemia of infancy, 887 

Psoriasis, 372 

Pulmonary artery in infants, 56 ; transposi- 
tion of, 721 

Pulmonary orifice, the, lesions of, in con- 
genital disease, 724 ; atresia, 725 ; insuf- 
ficiency, 745; stenosis, 745; stenosis of 
the conus arteriosus, 725 

Pulse, at term, 36 ; in infancy and child- 
hood, 71, 72. ( Vide, also, symptoms of 
the especial disease. ) 

Purpura, 998 ; fulminans, 1000 ; haemor- 
rhagica, 999 ; Henoch's, 999 ; rheumatica. 
998 ; simplex, 998 

Pyaemia of the bone, 511 

Pyelitis, acute, 862 ; chronic, 864 

Pyelonephritis, acute, 862 

Pyonephrosis, 864 



INDEX. 



1019 



Q. 

Quartan parasite, 483, 484 
Quinine, dose of, in malaria, 489 

R. 

Kachischisis, 301 

Kanula, 293 

Eeaetion of degeneration, 962 

Kectum, imperforate, 307 ; malformations 
about the, 307; reflex symptoms of the, 949 

Recurrent vomiting, 774 

Red blood-corpuscles, 877, 880 

Reflex cough, 947 

Reflex symptoms, of the bladder. 948 ; of 
the ear, 944 ; of the heart, 948 ; of the 
larynx, 944 ; of the lung, 946 ; of the 
rectum, 949 ; of the stomach 948 ; of 
the vagina, 948 

Retarded speech, 938 

Retropharyngeal abscess, 656 

Respirations at term, 30, 36, 72 ; in infancy, 
53 ; in infancy and childhood, 72 

Retinitis in scarlet fever, 573 

Rhachitis, 326 ; acute, 333 ; congenital, 342 ; 
diagnosis, 338 ; foetal, 342 ; late, 327 ; of 
adolescence, 327 ; pathology, 329 ; prog- 
nosis, 340 ; rosary, 334 ; symptoms, 332 ; 
treatment, 341 

Rhagades in hereditary syphilis, 528. 

Rheumatic fever, 514 ; subcutaneous fibrous 
nodules in, 519 

Rheumatism, acute articular, 514 ; chronic. 
1003 ; muscular, 1001 

Rhinitis, 640; acute, 640; atrophic, 643; 
hypertrophic, 642 ; purulent, 642 

Rhus toxicodendron, 364 
venenata, 364 

Rickets (vide Rhachitis), 326 

Ringworm, 359 

Bitter's disease, 362 

Rontgen light, 253 

Rosary in rhachitis, 334 

Rose-spots in typhoid fever, 450 ; typhoid 
bacilli in the, 452 

Rotch's experimental work on pericarditis, 
757 

Rotheln. ( Vide Rubella. ) 

Rubeola. ( Vide Measles. ) 

Rubella, 593 

Rupia, 526 

S. 

Salicylates, dose of the, 517 

Salivary glands at term, 38 ; development 
of, 83 

Salt solution, normal, dose for subcutaneous 
injection of, 504 

Santonin, dose of, 830 

Sarcoma of the brain, 978 

Scabies, 355 

Scanning speech, 987 

Scapulodynia, 1001 

Scarlatina, vide Scarlet fever ; sine erup- 
tione, 566 

Scarlet fever, 543 ; contagium, 545 ; eti- 
ology, 543 ; incubation, 554 ; pathology, 
546 ; pseudo-relapses in, 365 ; recrudes- 
cence, 566 ; reinfections, 365 ; relapses, 
365 ; sine eruptione, 566 ; variations in 
the type, 554 



Scarlet fever, benign form of, 554 ; compli- 
cations of. 568 ; desquamation, 
555 ; diagnosis, 557 ; efflorescence, 
555 ; isolation and disinfection, 
562 ; prodromata, 554 ; prognosis, 
557 ; prophylaxis, 558 ; symptoms, 
554 ; treatment, 559 ; variations 
in the type, 565 
malignant form of, 578 

Schonlein's disease, 998 

School, influence of, on the child, 108 

Sciatica, 970 

Sclerema neonatorum, 322 

Scleroderma, 379 

Sclerosis, insular or disseminated. 987 

Scoliosis in rhachitis, 336 

Scorbutus, 344 

Scrofula, 390, 432 

Scrofuloderma, 432 

Scurvy, 344 

Sebaceous glands at term, 38 

Seborrhcea capitis of infants, 359 

Septic endocarditis, 739 

Senna, dose of, 832 

Separated milk, definition of, 223 

Shoes for children, 102 

Sight, function of, at term, 37 

Sigmoid flexure in infancy and childhood, 70 

Simulated diseases. 935 

Skeletons, infantile, 87 

Skin, 81 ; at term, 21 ; diseases of the, 355 ; 
in cerebro-spinal meningitis, 435, 438 ; in 
measles, 581 ; in scarlet fever, 546 ; in 
syphilis, 525 ; in tuberculosis, 432 

Skoda's resonance, 710 

Sleep, amount of. for infants and children, 
106 

Small intestines at term, 36 ; development 
of, 68 

Small-pox, 595 ; modified, 599. ( Vide 
Varioloid. ) 

Smell, function of, at term, 38 

Snuffles in hereditary syphilis, 524 

Soft palate at term, 29 

Spasmus nutans, 944 

Spastic paralysis, hereditary, 989 

Specific infectious diseases, 381 

Speech, retarded, 938 

Spigelia, dose of, 832 

Spina bifida, 298 

Spinal meningocele, 288 

Spinal paralvsis, infantile, 958 ; temporary, 
961 

Spine, the, 39 ; at term, 22 ; curves, 41 ; 
flexibility, 40 ; length, 40 ; surface anat- 
omy, 41 ; in rhachitis, 338 ; tuberculosis 
of, 429 

Spleen, diseases of the, 840 ; in childhood, 
57 ; in cerebro-spinal meningitis, 435 ; in 
rhachitis, 331 ; in syphilis, 523 ; in ty- 
phoid, 450 ; in tuberculosis, 431 

Splenic myelogenous leukaemia, 882 

Spondylitis, tubercular, 407 

Spray for throat, 655 

Status lymph aticus, 1000 

Sternum, the, at term, 30 

Stomach, the, at term, 34; capacity, 58; 
development, 58 ; developmental diseases,, 
774 ; malformations, 774 ; malpositions, 
774 



1020 



INDEX. 



Stomach, diseases of the, 773 ; American Pe- 
diatric Society's classification of the, 
769, 773 ; general considerations, 773 
functional diseases of the, 774 ; acute 
gastric indigestion (acute dyspepsia), 
778 ; acute nervous vomiting, 774 ; 
chronic gastric indigestion (chronic 
dyspepsia), 779 ; cyclic or persistent 
vomiting, 774 ; elimi native, 782 ; gas- 
tralgia, 777 
organic diseases of the, 783 ; acute gas- 
tritis, 789 ; chronic gastritis, 792 ; 
contraction, 783 ; dilatation, 783 ; 
new growths, 789 ; ulcers, 787 
reflex symptoms of the, 948 
Stomach-tube, use of the, 781 
Stomach-washing, technique of, 780 
Stomatitis catarrhalis, 617 ; exanthematica, 
617; gangrenosa, 629 ; herpetica, 620 
hyphomycetica, 626 ; mycetogenetica, 625 
pseudo-membranosa, 629 ; simplex, 617 
traumatica, 617 ; ulcerosa, 622 
Strawberry tongue in scarlet fever, 555 
Stridor, congenital, 660 
Strychnine, doses of, in children, 470 
Subarachnoid space, 47 
Sudamina, 365 

Sugar in human milk, 126, 127, 129 
Sugar-measure, 225 

Suprarenal capsule at term, 33 ; in child- 
hood, 57 
Sweat-glands, the, at term, 38 ; development 

of, 82 
Sydenham's chorea, 916 
Synovitis, acute purulent, of infants, 511 
Syphilis, 520; acquired, 520; cerebral or 
intracranial, 978, 980 ; congenital, 
vide Syphilis, hereditary ; immu- 
nity, 522; lesions of the skin, 525; 
miscarriages in, 521, 534 ; mouth in, 
527 ; of the new-born, 521 ; retarded, 
521 ; pseudo-paralysis of the new- 
born in, 528 ; wet-nurse in cases of, 
531 
hereditary, 520; Colles's law in, 521; 
inheritance and transmission in, 
521 ; pathology, 522 ; post-con- 
ceptional, 521 ; retro-infection in, 
521 
early manifestations of, 524 ; cranio- 
tabes in, 524, 529 ; efflorescence, 
529 ; snuffles, 524 ; symptoms, 
524 ; plaques muqueuses, 528 ; 
diagnosis, 529 ; prognosis, 530 ; 
treatment, 530 
late manifestations of, 536 ; Hutch- 
inson's teeth in, 526 ; symptoms, 
536; treatment, 538 
Syphilitic gumma of the brain, 978, 980 
Syphilitica hemorrhagica neonatorum, 526 
Syringomyelia, 989 
Syringo-myelocele, 298 



T. 



Tabes mesenterica, 392 

Tachycardia in exophthalmic goitre, 906 

Taenia mediocanellata or saginata, 832 

solium, 832 
Taste, function of, at term, 38 



Teeth, the, at term, 29 ; development of, 49 ; 
in syphilis, 526. ( Vide, also, Dentition. ) 

Temperature at term, 36 ; in infants, 70. 
( Vide symptoms of the especial disease. ) 

Temporary amnesia, 937 
aphasia, 937 

Teratoma, 978 

Tertian parasite, 483, 484 

Testicle, the, in syphilis, 523 ; tuberculosis of, 
431 ; tumors of, 307, 870 ; undescended, 306 

Tetanus neonatorum, 496 

Tetany, 942 

Thomsen's disease, 924 

Thorax, the, at term, 30 ; development of, 
51 ; diameters of, 51 ; ossification of, 51 ; 
in rhachitis, 334 

Throat, the, in diphtheria, 461 ; in scarlet 
fever, 547, 568 ; in variola, 599 

Thrombosis of the cerebral sinuses, 975 

Thrush, 626, 628, 629 

Thymic asthma, 907 

Thymus gland, the, anatomy and relations 
of, 53, 908 ; at term, 32 ; diseases of the, 
907 ; tuberculosis of, 430 

Thyroid gland, the, 85 ; congenital absence 
of, 901 ; diseases of, 899 ; dose of the ex- 
tract of, 902 ; enlargement of, in exophthal- 
mic goitre, 906 ; hyperemia of, 900 ; in 
measles, 592 ; tuberculosis of, 430 ; tumors 
of, 907 

Tinea circinata, 359 ; favosa, 360 ; tricophy- 
tina, 359 ; tonsurans, 359 ; versicolor, 360 

Toes in the new-born, 310 

Tongue at term, 29 

Tongue-tie, 292 

Tonsillitis, 649 ; acute, 649 ; acute cryptic, 
649 ; acute follicular, 649 ; chronic, 652 

Tonsils, 28 ; hypertrophied, 652 

Topographical anatomy of the early periods, 
of life, 88 

Torticollis, acute, 1001 

Touch at term, 38 

Tourette's treatment of epilepsy, 929 

Trachea, diseases of the, 665 

Tracheitis in measles, 593 

Tremor, 942 

Tricophyton tonsurans, 359 

Tricuspid insufficiency, 744 ; stenosis, 745 

Tricuspid orifice in congenital disease, in- 
sufficiency of the, 726 ; stenosis of the 726 

Trional, dose of, 457 

Trousseau's symptom, 943 

Trunk, the, disease of, in the new-born, 296 

Tubercle bacillus, mode of entrance, 382 

Tubercular dactylitis, 430 

meningitis, 406 ; infantile form. 410 ;. 
recurrent, 421-423 

Tuberculin test, 385 

Tuberculosis, 381 ; bladder, 431 ; brain, 406, 
978 ; cerebro-spinal system, 405 ; gastro- 
enteric tract, 399 ; general diagnosis, 385 ; 
general etiology, 381 ; general pathology, 
383 ; general symptomatology, 385 ; gen- 
eral treatment," 386 ; hip, 429 ; in acute- 
broncho-pneumonia, 700 ; intestines, 399 
joints, 427 ; kidney, 431 ; knee, 429 
larynx, 393 ; liver, 431 ; localized, 389 
lungs, 393 ; meninges, 978 ; in measles 
592 ; pancreas, 430 ; peritoneum, 401 
predisposition to, 383 ; prophylaxis, 384 



INDEX. 



1021 



skin, 432 ; spine, 429 ; spleen, 431 ; tes- 
ticle, 431 ; thymus gland, 430 ; thyroid 
gland, 430 ; trachea, 393 
Tuberculosis, acute miliary, 387 ; of the lung, 
395 ; simulating infantile atrophy, 
388 ; simulating typhoid fever, 387 
general, 386 ; chronic, 389 
of the lymph-nodes, 389 ; bronchial, 

392 ; cervical, 390 ; mesenteric, 392 
relation of bovine, to human tubercu- 
losis, 381 
Tubular indigestion, 798 
Tumor albus, 429 
Tumors, intracranial, 978 
Turpentine stupe, 456 
Typhoidal ileo-colitis, 447 
Typhoid bacillus in cerebro-spinal fluid, 450 
Typhoid fever, 447 ; complications and se- 
quelae, 451 ; diagnosis, 451 ; diazo-reaction 
in, 450 ; differential diagnosis, 452 ; etiol- 
ogy, 447 ; incubation, 449 ; in infancy and 
early childhood, 447 ; in the foetus, 447 ; 
pathology, 448 ; prognosis, 454 ; symp- 
toms, 449 ; treatment. 454 ; Widal reaction 
in, 450 
Typhus fever, 459 

U. 

Ulcers of the stomach, 783, 786 

Umbilical arteries, post-natal changes in the, 
55 
cord, 21, 39, 82 
hernia, congenital, into the cord, 302 ; 

in the new-born, 302 
vein, post-natal changes in the, 55 

Umbilicus, fungus of the, 302 ; polypus of 
the, 302 

Unclassified diseases, 997 

Undescended testicle, 306 

Uraemia in acute diffuse nephritis, 855 ; in 
chronic interstitial nephritis, 858 ; treat- 
ment of, 574. ( Vide, also, symptoms of 
the especial disease.) 

Uric acid infarction at term, 34 

Urine, at term, 39, 85 ; diazo-reaction in the, 
452 ; in acute cystitis, 867 ; in active hy- 
peraemia, 851 ; in acute pyelitis and pyelo- 
nephritis, 863 ; in acute diffuse nephritis, 
854 ; in amyloid infiltration, 859 ; in 
chronic cystitis, 867 ; in chronic interstitial 
nephritis, 858 ; in chronic parenchymatous 
nephritis i 856 ; in chronic pyelitis, 864 ; 
in chyluria, 850 ; in diabetes insipidus, 
1004 ; in diabetes mellitus, 1006 ; in gly- 
cosuria, 851 ; in haematuria, 849 ; in haema- 
globinuria, 849 ; in hydronephrosis, 865 ; 
incontinence of, 871 ; in infancy and child- 
hood, 85 ; in passive hyperaemia, 852 ; 
in physiological albuminuria, 847 ; in 
scarlet fever, 556 ; in subacute glomerular 
nephritis, 856. ( Vide, also, symptoms of 
the especial disease. ) 

Urotropin, dose of, 867 

Urticaria, 367 

Uterus at term, 36 



Uvula at term, 29 

elongation of the, 



655 



V. 

Vaccinia, 601 

Vaccination, 601 

Vagina, occlusion of the, 307 ; reflex symp- 
toms, 948 

Varicella, 605 ; complications, 608 ; diag- 
nosis, 608 ; etiologv, 605 ; gangrenous, 
606, 608 ; pathology" 606 ; prognosis, 609 ; 
symptoms, 606 ; treatment, 609 

Variola, 595 ; complications, 599 ; confluent 
form, 598 ; diagnosis, 600 ; discrete form, 
597 ; etiology, 595 ; hemorrhagic form, 
598 ; incubation, 597 ; modified form, 
598 ; pathology, 595 ; prognosis, 601 ; 
symptoms, 597 ; treatment, 601 

Varioloid, 599 

Veins at term, 32 

Ventricular septum, defect of the, 724 

Vermiform appendix, 815 (vide, also, Appen- 
dicitis) ; in infancy and childhood, 70 

Vernix caseosa, 21 

Verrucae, 375 

Verrucous endocarditis, 721 

Vertigo, 940 

Vitality at term, 37 

Voice, function of, at term, 37 ; develop- 
ment of, 82 

Volvulus, 811 

Vomiting, acute nervous, 774 ; cyclic or re- 
current, 774. ( Vide, also, symptoms of 
the especial disease. ) 

Von Jaksch's pseudo-leukaemia of infancy, 
887 

Vulvo vaginitis, 868 

W. 

Warts, 375 

Waxy rigidity, 935 

Weaning, 157 

Weight, at term, 36 ; development of, 55 ; 
general figures of, 79 ; of infants and chil- 
dren, 73 ; of premature infants, 265 ; rela- 
tion of nutrition to, 73-81 

Westcott's general formulae, 235 ; tables of 
dilutions of creams, 232 

Wet-nurses, 162 ; diet of, 163 ; in cases of 
syphilis, 531 

Wheat-jelly, 240 

Wheat-water, 240 

Whey, definition of, 223 ; average analysis 
of, 227 ; formulae for cream and, 238 ; in 
percentage feeding, 200 ; preparation of, 
235 ; with dilutions of cream, 233 

Whey-cream mixtures, prescriptions for, 201, 
215, 216, 274, 275 

Whey-pro teids. ( Vide Lactalbumin. ) 

White blood-corpuscles, 881 

Whiskey, doses of, 456 

Whole milk, definition of, 223 ; average 
analysis of, 223 

Whooping-cough, 505 

Widal reaction, 451 

Winckel's disease, 314 



OCT 



-o m 



